Publications by authors named "Mariano E Menendez"

164 Publications

Evaluation of the National Institutes of Health-Supported Relative Citation Ratio among Fellowship trained American Orthopaedic Joint Reconstruction Surgery Faculty: A New Bibliometric Measure of Scientific Influence.

J Arthroplasty 2022 Aug 5. Epub 2022 Aug 5.

Orthopedic Surgery, Monmouth Medical Center, Long Branch, NJ, USA.

Background: The Relative Citation Ratio (RCR), a novel National Institutes of Health-Supported measure of research productivity, allows for accurate interdisciplinary comparison of publication influence. This study evaluates the RCR of fellowship trained Adult Reconstructive Orthopaedic Surgeons with the goal of analyzing potentially influential physician demographics.

Methods: Adult Reconstruction Accreditation Council for Graduate Medical Education (ACGME) fellowship-trained faculty for orthopaedic residency programs were identified via departmental websites. The National Institutes of Health's iCite database was retrospectively reviewed for mean RCR, weighted RCR, and publication count by surgeon. Multivariate analyses were performed using the Wilcoxson rank-sum tests and Analyses of Variance testings (ANOVA) to compare sex, career length, academic rank, and professional degrees in addition to an M.D. or D.O. Significance was considered p<0.05.

Results: A total of 488 fellowship trained Adult Reconstruction faculty from 144 programs were included in the analysis. Overall, faculty recorded a median RCR of 1.65 (IQR 1.01 - 2.28) and a median weighted RCR of 16.59 (IQR 3.98 - 61.92). Weighted RCR and total number of publications were associated with academic rank and career longevity, while mean RCR was associated with academic rank. Median RCR ranged from 1.12 to 1.87 for all subgroups.

Conclusion: Adult Reconstruction faculty are exceptionally productive and generate highly impactful studies as evidenced by the high median RCR value relative to the National Institute of Health standard value of 1.0. Our data has important implications in the assessment of grant outcomes, promotion, and continued evaluation of research influence within the hip and knee community.
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http://dx.doi.org/10.1016/j.arth.2022.07.022DOI Listing
August 2022

Evaluation of the National Institutes of Health-supported relative citation ratio among American orthopedic spine surgery faculty: A new bibliometric measure of scientific influence.

N Am Spine Soc J 2022 Sep 14;11:100143. Epub 2022 Jul 14.

Professional Orthopedic Associates, Tinton Falls, NJ, USA.

Background: Publication metrics have been traditionally used to compare research productivity amongst academic faculty. However, traditional bibliometrics lack field-normalization and are often biased towards time-dependent publication factors. The National Institutes of Health (NIH) has developed a new, field-normalized, article-level metric, known as the "relative citation ratio" (RCR), that can be used to make accurate self, departmental, and cross-specialty comparisons of research productivity. This study evaluates the use of the RCR amongst academic orthopedic spine surgery faculty and analyzes physician factors associated with RCR values.

Methods: A retrospective data analysis was performed using the iCite database for all fellowship trained orthopedic spine surgery (OSS) faculty associated with Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopedic surgery residency program. Mean RCR, weighted RCR, and total publication count were compared by sex, career duration, academic rank, and presence of additional degrees. A value of 1.0 is the NIH-funded field-normalized standard. Student t-tests were used for two-group analyses whereas the analysis of variance tests (ANOVA) was used for between-group comparisons of three or more subgroups. Statistical significance was achieved at P < 0.05.

Results: A total of 502 academic OSS faculty members from 159 institutions were included in the analysis. Overall, OSS faculty were highly productive, with a median RCR of 1.62 (IQR 1.38-2.32) and a median weighted RCR of 68.98 (IQR 21.06-212.70). Advancing academic rank was associated with weighted RCR, career longevity was associated with mean RCR score, and male sex was associated with having increased mean and weighted RCR scores. All subgroups analyzed had an RCR value above 1.0.

Conclusions: Academic orthopedic spine surgery faculty produce impactful research as evidenced by the high median RCR relative to the standard value set by the NIH of 1.0. Our data can be used to evaluate research productivity in the orthopedic spine community.
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http://dx.doi.org/10.1016/j.xnsj.2022.100143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9344340PMC
September 2022

Clinical Faceoff: Latarjet versus Free Bone Block Procedures for Anterior Shoulder Instability.

Clin Orthop Relat Res 2022 Jul 18. Epub 2022 Jul 18.

Department of Orthopedic Surgery, Mayo Clinic Arizona, Scottsdale, AZ, USA.

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http://dx.doi.org/10.1097/CORR.0000000000002324DOI Listing
July 2022

Defining Minimal Clinically Important Difference and Patient Acceptable Symptom State After the Latarjet Procedure.

Am J Sports Med 2022 08 18;50(10):2761-2766. Epub 2022 Jul 18.

Oregon Shoulder Institute at Southern Oregon Orthopedics, Medford, Oregon, USA.

Background: The Latarjet procedure is one of the most well-established treatment options for anterior shoulder instability. However, meaningful clinical outcomes after this surgery have not been defined.

Purpose: This study aimed to establish the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) for commonly used outcome measures in patients undergoing the Latarjet procedure and determine correlations between preoperative patient characteristics and achievement of MCID or PASS.

Study Design: Case series; Level of evidence, 4.

Methods: A multicenter retrospective review at 4 institutions was performed to identify patients undergoing primary open Latarjet procedure with minimum 2-year follow-up. Data collected included patient characteristics (age, sex, sports participation), radiological parameters (glenoid bone loss, off-track Hill-Sachs lesion), and 4 patient-reported outcome measures (collected preoperatively and 2 years postoperatively): the American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), the visual analog scale (VAS) for pain, and the Western Ontario Shoulder Instability Index (WOSI). The MCID and PASS for each outcome measure were calculated, and Pearson and Spearman coefficient analyses were used to identify correlations between MCID or PASS and preoperative variables (age, sex, sports participation, glenoid bone loss, off-track Hill-Sachs lesion).

Results: A total of 156 patients were included in the study. The MCID values for ASES, SANE, VAS pain, and WOSI were calculated to be 9.6, 12.4, 1.7, and 254.9, respectively. The PASS values for ASES, SANE, VAS pain, and WOSI were 86.0, 82.5, 2.5, and 571.0, respectively. The rates of patients achieving MCID were 61.1% for VAS pain, 71.6% for ASES, 74.1% for SANE, and 84.2% for WOSI. The rates of achieving PASS ranged from 78.4% for WOSI to 84.0% for VAS pain. There was no correlation between any of the studied preoperative variables and the likelihood of achieving MCID or PASS.

Conclusion: This study defined MCID and PASS values for 4 commonly used outcome measures in patients undergoing the Latarjet procedure. These findings are essential for incorporating patient perspectives into the clinical effectiveness of the Latarjet procedure and provide valuable parameters for the design and interpretation of future clinical trials.
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http://dx.doi.org/10.1177/03635465221107939DOI Listing
August 2022

Current Status Regarding the Safety of Inpatient Versus Outpatient Total Shoulder Arthroplasty: A Systematic Review.

HSS J 2022 Aug 5;18(3):428-438. Epub 2021 Jul 5.

Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.

Background: Surgeons have begun to transition total shoulder arthroplasty (TSA) to the outpatient setting in order to contain costs and reallocate resources.

Purpose: The purpose of this systematic review was to evaluate the safety and cost of outpatient TSA by assessing associated complication rates, clinical outcomes, and total treatment charges.

Methods: The MEDLINE, Embase, and Cochrane Library online databases were queried in March 2020 for studies on outpatient shoulder arthroplasty. Inclusion criteria were (1) a study population undergoing TSA, (2) discharge on the day of surgery, and (3) inclusion of at least 1 reported outcome.

Results: Of 20 studies identified that met inclusion criteria, 14 were comparative studies involving an inpatient control group, 2 of which were matched by age and comorbidities. The remaining studies used control groups consisting of inpatient TSAs who were older or more medically infirm according to American Society of Anesthesiologists (ASA) or Charlson Comorbidity Index (CCI) scores. The combined average age of the outpatient and inpatient groups was 66.5 and 70.1 years, respectively. Patients who underwent outpatient TSA had similar rates of readmissions, emergency department visits, and perioperative complications in comparison to inpatients. Patients also reported comparably high levels of satisfaction with outpatient procedures. Four economic analyses demonstrated substantial cost savings with outpatient TSA in comparison to inpatient surgery.

Conclusion: In carefully selected patients, outpatient TSA appears to be equally safe but less resource intensive than inpatient arthroplasty. Nonetheless, there remains a need for larger prospective studies to decisively characterize the relative safety of outpatient TSA among patients with similar baseline health.
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http://dx.doi.org/10.1177/15563316211019398DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9247601PMC
August 2022

Evaluation of the Relative Citation Ratio Among Academic Orthopedic Hand Surgeons: A Novel Measure of Research Impact.

Cureus 2022 May 26;14(5):e25362. Epub 2022 May 26.

Orthopedic Surgery, Central Jersey Hand Surgery, Eatontown, USA.

Background Publication metrics such as article citation count and the Hirsch index (h-index) are used to evaluate research productivity among academic faculty. However, these bibliometric indices are not field-normalized and yield inaccurate cross-specialty comparisons. We evaluate the use of the relative citation ratio (RCR), a new field-normalized article-level metric developed by the National Institutes of Health (NIH), among academic orthopedic hand surgeons and analyze physician factors associated with RCR values. Methods: A retrospective analysis was performed using the iCite database. Fellowship-trained orthopedic hand surgeons affiliated with accredited orthopedic surgery residency programs were included. Mean RCR, weighted RCR, and publication count were compared by sex, career duration, academic rank, and presence of additional degrees. Mean RCR represents the total number of citations per year of a publication divided by the average number of citations per year received by NIH-funded papers in the same field. Mean RCR serves as a measure of overall research impact. A value of 1.0 is the NIH-funded field-normalized standard. Weighted RCR is the sum of all article-level RCR scores and represents overall research productivity. Results A total of 620 academic orthopedic hand surgeons from 164 programs were included. These physicians produced highly impactful research with a median RCR of 1.27 (interquartile range [IQR] 0.86-1.66). Weighted RCR was associated with advanced degree, advanced academic rank, and longer career duration. Conclusions Fellowship-trained academic orthopedic hand surgeons produce highly impactful research. Our benchmark data can be used to assess grant outcomes, promotion, and continued evaluation of research productivity within the hand surgery community.
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http://dx.doi.org/10.7759/cureus.25362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9236682PMC
May 2022

Hip Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents.

Arthrosc Sports Med Rehabil 2022 Jun 17;4(3):e1179-e1184. Epub 2022 May 17.

Professional Orthopedic Associates, Tinton Falls, New Jersey, U.S.A.

Purpose: The purpose of this study was to evaluate case volume and variability of hip arthroscopy exposure among graduating orthopaedic residents.

Methods: The Accreditation Council for Graduate Medical Education (ACGME) surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents were assessed. Arthroscopy procedures of the pelvis/hip were identified. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.

Results: There was no change in the number of hip arthroscopy procedures between 2016 and 2020 [average: 8.4 ± 10 (range: 0 to 87) vs. 9.8 ± 12 (range: 0 to 101)] ( = .995). There was a wide variability in case volume among residents. The 90th percentile of residents performed 24 cases in 2020, compared to 2 cases in the 30th percentile and 0 cases amongst the 10th percentile of residents.

Conclusions: Despite the growing popularity of hip arthroscopy, resident exposure to this highly technical procedure remains limited, with about one-third of residents performing 2 or less cases by graduation.

Clinical Relevance: Understanding case volume and variability is important for orthopaedic surgery programs to ensure that graduating residents are gaining adequate exposure.
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http://dx.doi.org/10.1016/j.asmr.2022.04.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9210477PMC
June 2022

Superior Capsule Reconstruction and Lower Trapezius Transfer for Irreparable Posterior-Superior Rotator Cuff Tear: A Case Report.

JBJS Case Connect 2022 04 8;12(2). Epub 2022 Jun 8.

Rush University Medical Center, Department of Orthopedic Surgery, Chicago, Illinois.

Case: A 49-year-old right-hand-dominant male weightlifter was referred with persistent left shoulder pain, weakness, and range of motion limitations after failed arthroscopic rotator cuff repair and subsequent arthroscopic debridement for a massive posterior-superior supraspinatus and infraspinatus tear. The patient underwent a superior capsular reconstruction (SCR) with lower trapezius (LT) transfer to re-establish rotator cuff function.

Conclusion: LT transfer in addition to SCR may be a promising modality to treat massive, irreparable posterior-superior rotator cuff tears in young adults. LT transfer can optimize external rotation, whereas SCR may more adequately address pain and forward elevation.
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http://dx.doi.org/10.2106/JBJS.CC.22.00098DOI Listing
April 2022

Patients with limited health literacy have worse preoperative function and pain control and experience prolonged hospitalizations following shoulder arthroplasty.

J Shoulder Elbow Surg 2022 Jun 4. Epub 2022 Jun 4.

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA.

Background: Patients with limited health literacy (LHL) may have difficulty understanding and acting on medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine (1) the prevalence of LHL in patients undergoing inpatient shoulder arthroplasty, (2) the association of LHL with the degree of preoperative symptom intensity and magnitude of limitations, (3) and the effects of LHL on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption.

Methods: We retrospectively identified 230 patients who underwent elective inpatient reverse or anatomic shoulder arthroplasty between January 2018 and May 2021 from a prospectively maintained single-surgeon registry. The health literacy of each patient was assessed preoperatively using the validated 4-item Brief Health Literacy Screening Tool. Patients with a Brief Health Literacy Screening Tool score ≤ 17 were categorized as having LHL. The outcomes of interest were preoperative patient-reported outcome scores and range of motion, LOS, total postoperative inpatient opioid consumption, and total inpatient costs as calculated using time-driven activity-based costing methodology. Univariate analysis was performed to determine associations between LHL and patient characteristics, as well as the outcomes of interest. Multivariable linear regression modeling was used to determine the association between LHL and LOS while controlling for potentially confounding variables.

Results: Overall, 58 patients (25.2%) were classified as having LHL. Prior to surgery, these patients had significantly higher rates of opioid use (P = .002), more self-reported allergies (P = .007), and worse American Shoulder and Elbow Surgeons scores (P = .001), visual analog scale pain scores (P = .020), forward elevation (P < .001), and external rotation (P = .022) but did not significantly differ in terms of any additional demographic or clinical characteristics (P > .05). Patients with LHL had a significantly longer LOS (1.84 ± 0.92 days vs. 1.57 ± 0.58 days, P = .012) but did not differ in terms of total hospitalization costs (P = .65) or total inpatient opioid consumption (P = .721). On multivariable analysis, LHL was independently predictive of a significantly longer LOS (β, 0.14; 95% confidence interval, 0.02-0.42; P = .035).

Conclusion: LHL is commonplace among patients undergoing elective shoulder arthroplasty and is associated with greater preoperative symptom severity and activity intolerance. Its association with longer hospitalizations suggests that health literacy is an important factor to consider for postoperative disposition planning.
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http://dx.doi.org/10.1016/j.jse.2022.05.001DOI Listing
June 2022

Neighborhood socioeconomic disadvantage does not predict outcomes or cost after elective shoulder arthroplasty.

J Shoulder Elbow Surg 2022 Jun 6. Epub 2022 Jun 6.

Midwest Orthopaedics at Rush, Rush University, Chicago, IL, USA; Oregon Shoulder Institute at Southern Oregon Orthopedics, Medford, OR, USA.

Background: There is growing evidence that the variation in value of shoulder arthroplasty may be mediated by factors external to surgery. We sought to determine if neighborhood-level socioeconomic deprivation is associated with postoperative outcomes and cost among patients undergoing elective shoulder arthroplasty.

Methods: We identified 380 patients undergoing elective total shoulder arthroplasty (anatomic or reverse) between 2015 and 2018 in our institutional registry with minimum 2-year follow-up. Each patient's home address was mapped to the area deprivation index in order to determine the level of socioeconomic disadvantage. The area deprivation index is a validated composite measure of 17 census variables encompassing income, education, employment, and housing conditions. Patients were categorized into 3 groups based on socioeconomic disadvantage (least disadvantaged [deciles 1-3], middle group [4-6], and most disadvantaged [7-10]). Bivariate analysis was performed to determine associations between the level of socioeconomic deprivation with hospitalization time-driven activity-based costs and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and pain intensity scores.

Results: Overall 19% of patients were categorized as most disadvantaged. These patients were found to have equivalent preoperative pain intensity (P = .51), SANE (P = .50), and ASES (P = .72) scores compared to the middle and least disadvantaged groups, as well as similar outcome improvement at 2 years postoperatively (ASES): least disadvantaged group [35.7-84.3], middle group [35.1-82.4], and most disadvantaged group [37.1-84.0] [P = .56]; SANE: least disadvantaged group [31.8-87.1], middle group [30.8-84.8], and most disadvantaged group [34.2-85.1] [P = .42]; and pain: least disadvantaged group [6.0-0.97], middle group [6-0.97], and most disadvantaged group [5.6-0.80] [P = .88]. No differences in hospitalization costs were noted between groups (P = .77).

Conclusions: Patients undergoing elective shoulder arthroplasty residing in the most disadvantaged neighborhoods demonstrate equivalent preoperative and postoperative outcomes as others, without incurring higher costs. These findings support continued efforts to provide equitable access to orthopedic care across the socioeconomic spectrum.
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http://dx.doi.org/10.1016/j.jse.2022.04.023DOI Listing
June 2022

The Definition of Periprosthetic Osteolysis in Shoulder Arthroplasty: A Systematic Review of Grading Schemes and Criteria.

JBJS Rev 2022 05 1;10(5). Epub 2022 May 1.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois.

Background: Periprosthetic osteolysis is a known complication after shoulder arthroplasty that may lead to implant loosening and revision surgery. To date, there is no consensus in the shoulder arthroplasty literature regarding the definition of osteolysis or the grading criteria, thus making it difficult to quantify and compare outcomes involving this complication. The purpose of this study was to perform a systematic review of the literature to assess how periprosthetic osteolysis in shoulder arthroplasty is defined and evaluated radiographically.

Methods: A systematic review of MEDLINE, Scopus, Cochrane, and CINAHL was performed in August 2021 for studies that provided a definition and/or grading criteria for osteolysis in shoulder arthroplasty. Only studies with a minimum of 2 years of radiographic follow-up were included.

Results: Thirty-four articles met the inclusion criteria. After consolidating studies by the same primary author that included the same grading criteria, 29 studies were examined for their definition and grading criteria for osteolysis. Of these, 19 (65.5%) evaluated osteolysis surrounding the glenoid and 18 (62.1%) evaluated osteolysis surrounding the humerus. There was considerable heterogeneity in the systems used to grade periprosthetic osteolysis surrounding the glenoid, whereas humeral periprosthetic osteolysis was often categorized via visualization into binary or categorical groups (e.g., presence versus absence; mild, moderate, or severe; partial versus complete). Four studies (13.8%) provided novel measurements for assessing either glenoid or humeral osteolysis.

Conclusions: Considerable heterogeneity exists in the assessment and grading of periprosthetic osteolysis in shoulder arthroplasty. The most common grading systems were binary and used qualitative visual interpretation, making them relatively subjective and prone to bias. Quantitative measurements of osteolysis were infrequently utilized. A standardized method of assessing osteolysis would be of value to facilitate communication and research efforts.
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http://dx.doi.org/10.2106/JBJS.RVW.22.00002DOI Listing
May 2022

Fracture Dislocations of the Proximal Humerus Treated with Open Reduction and Internal Fixation: A Systematic Review.

J Shoulder Elbow Surg 2022 May 20. Epub 2022 May 20.

Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA. Electronic address:

Background: The treatment of proximal humerus fracture-dislocations can be challenging given the extensive injury to the proximal humeral anatomy and increased risk of devascularization of the humeral head often seen in these injuries. The purpose of this study is to undertake a systematic review of the literature on the functional outcomes, rate of revision, and short- and long-term complications for proximal humerus fracture-dislocations treated with open reduction and internal fixation (ORIF).

Methods: The PubMed and OVID Embase databases were queried for literature reporting on proximal humerus fracture dislocations treated with ORIF. Data including study design, patient demographics, functional outcomes, and complications were recorded.

Results: Twelve studies including 294 patients with Neer type 2-, 3-, or 4-part proximal humerus fracture-dislocations met the criteria for inclusion. The mean patient age was 53.4 years (19-89 years) with an average follow-up of 2.9 years (1.15-4.9 years). At final follow-up, the mean Constant Score was 73.2 (52 - 87.3) and the mean Disabilities of the Arm Shoulder and Hand (DASH) score was 26.6 (17.5- 32). Avascular necrosis (AVN) was observed in 20.0% (0%-82.3%) and non-union was observed in 3.0% (0% - 7.7%) of patients. Conversion to arthroplasty was observed in 10.7% (5% - 20%) and a total reoperation was observed in 35.6% (11.8%-89.1%) of patients in studies explicitly reporting these outcomes. In addition to conversion to arthroplasty, common causes of reoperation were revision ORIF (5.2%) and hardware removal (22.2%).

Conclusion: Patients undergoing ORIF for proximal humerus fracture-dislocations have reasonable functional outcomes but relatively high AVN and reoperation rates. This information can be used to counsel patients and set expectations about the potential for further surgeries.
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http://dx.doi.org/10.1016/j.jse.2022.04.018DOI Listing
May 2022

An evidence-based approach to managing unexpected positive cultures in shoulder arthroplasty.

J Shoulder Elbow Surg 2022 May 2. Epub 2022 May 2.

Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Background: Unexpected positive cultures (UPCs) are very commonly found during shoulder arthroplasty when surgeons send intraoperative cultures to rule out periprosthetic joint infection (PJI) without clinical or radiographic signs of infection. Cutibacterium acnes is thought to be the most common bacteria cultured in this setting; however, the implications of an unexpected positive result are neither well defined nor agreed upon within the literature. The current review evaluates the incidence of UPCs and C acnes in reverse total arthroplasty; the clinical significance, if any, of these cultures; and various prognostic factors that may affect UPC incidence or recovery following PJI.

Methods: A systematic review was performed with PRISMA guidelines using PubMed, CINAHL, and Scopus databases. Inclusion criteria included studies published from January 1, 2000, to May 20, 2021, that specifically reported on UPCs, native or revision shoulder surgery, and any study that directly addressed one of our 6 proposed clinical questions. Two independent investigators initially screened 267 articles for further evaluation. Data on study design, UPC rate/speciation, UPC risk factors, and UPC outcomes were analyzed and described.

Results: A total of 22 studies met the inclusion criteria for this study. There was a pooled rate of 27.5% (653/2373) deep UPC specimen positivity, and C acnes represented 76.4% (499/653) of these positive specimens. Inanimate specimen positivity was reported at a pooled rate of 20.1% (29/144) across 3 studies. Male patients were more likely to have a UPC; however, the significance of prior surgery, surgical approach, and type of surgery conflicted across multiple articles. Patient-reported outcomes and reoperation rates did not differ between positive-UPC and negative-UPC patients. The utilization of antibiotics and treatment regimen varied across studies; however, the reinfection rates following surgery did not statistically differ based on the inclusion of antibiotics.

Conclusion: UPCs are a frequent finding during shoulder surgery and C acnes represents the highest percentage of cultured bacteria. Various preoperative risk factors, surgical techniques, and postoperative treatment regimens did not significantly affect the incidence of UPCs as well as the clinical outcomes for UPC vs. non-UPC patients. A standardized protocol for treatment and follow-up would decrease physician uncertainty when faced with a UPC from shoulder surgery. Given the results of this review, shoulder surgeons can consider not drastically altering the postoperative clinical course in the setting of UPC with no other evidence of PJI.
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http://dx.doi.org/10.1016/j.jse.2022.03.019DOI Listing
May 2022

Evaluation of the National Institutes of Health-supported relative citation ratio among American Shoulder and Elbow Surgeons fellowship faculty: a new bibliometric measure of scientific influence.

J Shoulder Elbow Surg 2022 Apr 30. Epub 2022 Apr 30.

Oregon Shoulder Institute at Southern Oregon Orthopedics, Medford, OR, USA; Midwest Orthopaedics at Rush, Rush University, Chicago, IL, USA.

Background: Publication metrics are used to evaluate and compare research productivity among academic faculty. However, traditional bibliometrics, such as the Hirsch index and article citation count, are limited by lack of field-normalization and yield inaccurate cross-specialty comparisons. Herein, we evaluate the use of a new field-normalized article-level metric developed by the National Institutes of Health (NIH), known as the relative citation ratio (RCR), among American Shoulder and Elbow Surgeons (ASES) fellowship faculty and analyzed physician factors associated with RCR values.

Methods: A retrospective data analysis was performed using the iCite database for all shoulder and elbow surgery fellowship faculty listed on the American Shoulder and Elbow Surgeons (ASES) directory as of November 14, 2021. Mean RCR, weighted RCR, and total publication count were compared by sex, career duration, academic rank, and presence of additional degrees. Mean RCR represents the total number of article citations per year of a publication divided by the average number of citations per year received by NIH-funded papers in the same field; mean RCR serves as a measure of overall research impact. A value of 1.0 is the NIH-funded field-normalized standard. The weighted RCR represents the sum of all article-level RCR scores and is a measure of overall research productivity. Student t tests were used for two-group analyses whereas analyses of variance were used for between-group comparisons of 3 or more subgroups.

Results: A total of 145 ASES fellowship faculty members from 33 fellowship programs were included in the analysis. Overall, ASES fellowship faculty produced highly impactful research with a median RCR of 1.8 (interquartile range [IQR] 1.4-2.3) and a median weighted RCR of 67.0 (IQR 21.1-212.7). Advanced academic rank and career longevity were associated with increased weighted RCR and total publication count. All subgroups analyzed had an RCR value above 1.0.

Conclusions: ASES fellowship faculty are exceptionally productive and produce highly impactful research, as evidenced by the high median RCR value relative to the benchmark NIH RCR value of 1.0. This information can be used as a standard to assess the improvement of grant outcomes, promotion, fellowship education, and continued evaluation of research productivity in the shoulder and elbow community.
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http://dx.doi.org/10.1016/j.jse.2022.03.017DOI Listing
April 2022

The Cost-Effectiveness of Extended Oral Antibiotic Prophylaxis for Infection Prevention After Total Joint Arthroplasty in High-Risk Patients.

J Arthroplasty 2022 Apr 25. Epub 2022 Apr 25.

Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts.

Background: Extended oral antibiotic prophylaxis may decrease rates of prosthetic joint infection (PJI) after total joint arthroplasty (TJA) in patients at high risk for infection. However, the cost-effectiveness of this practice is not clear. In this study, we used a break-even economic model to determine the cost-effectiveness of routine extended oral antibiotic prophylaxis for PJI prevention in high-risk TJA patients.

Methods: Baseline PJI rates in high-risk patients, the cost of revision arthroplasty for PJI, and the costs of extended oral antibiotic prophylaxis regimens were obtained from the literature and institutional purchasing records. These variables were incorporated in a break-even economic model to calculate the absolute risk reduction (ARR) in infection rate necessary for extended oral antibiotic prophylaxis to be cost-effective. ARR was used to determine the number needed to treat (NNT).

Results: Extended oral antibiotic prophylaxis with Cefadroxil in patients at high risk for PJI was cost-effective at an ARR in baseline infection rate of 0.187% (NNT = 535) and 0.151% (NNT = 662) for TKA and THA, respectively. Cost-effectiveness was preserved with varying costs of antibiotic regimens, PJI treatment costs, and infection rates.

Conclusion: The use of extended oral antibiotic prophylaxis may reduce PJI rates in patients at high risk for infection following TJA and appears to be cost-effective. However, the current evidence supporting this practice is limited in quality. The use of extended oral antibiotic prophylaxis should be weighed against the possible development of future antimicrobial resistance, which may change the value proposition.
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http://dx.doi.org/10.1016/j.arth.2022.04.025DOI Listing
April 2022

Antibiotic Spacers for Shoulder Periprosthetic Joint Infection: A Review.

J Am Acad Orthop Surg 2022 Apr 21. Epub 2022 Apr 21.

From the Rothman Orthopaedic Surgery, Rothman Institute, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA (Namdari), the Department of Orthopedics, Monmouth Medical Center, Long Branch, NJ (Sudah), the Midwest Orthopaedics at Rush, Rush University, Chicago, IL (Menendez), and the Oregon Shoulder Institute, Medford, OR (Denard).

Periprosthetic joint infection is a rare but potentially devastating complication of shoulder arthroplasty. The most conservative treatment approach is a two-stage revision involving interval placement of an antibiotic cement spacer. The purpose of this study was to contextualize the use of antibiotic spacers in the current treatment paradigm of shoulder periprosthetic joint infection and to review the history of shoulder spacers, the different types (eg, stemmed versus stemless and prefabricated versus handmade), the antibiotic composition and dosage, and their efficacy and complications.
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http://dx.doi.org/10.5435/JAAOS-D-21-00984DOI Listing
April 2022

Remplissage Yields Similar 2-Year Outcomes, Fewer Complications, and Low Recurrence Compared to Latarjet Across a Wide Range of Preoperative Glenoid Bone Loss.

Arthroscopy 2022 Apr 8. Epub 2022 Apr 8.

Oregon Shoulder Institute, Medford, Oregon, U.S.A.. Electronic address:

Purpose: The purpose of this study was to compare functional outcome, return to sport, satisfaction, postoperative recurrence, and complications in patients undergoing primary arthroscopic Bankart repair with remplissage (ABR) to primary Latarjet.

Methods: A multicenter retrospective study was performed on patients undergoing primary ABR or open Latarjet between 2013 and 2019 who had a minimum 2-year follow-up. Baseline and two-year range of motion (ROM), patient-reported outcomes (PROs: Western Ontario Shoulder Instability Index [WOSI], Single Assessment Numeric Evaluation [SANE], and visual analog scale [VAS] for pain) recurrence, return to sport, satisfaction, and complications were reviewed.

Results: This study included 258 patients, including 70 ABRs and 188 Latarjet procedures. Baseline demographics, ROM, and PROs were similar. Mean preop glenoid bone loss (GBL) (12.3% ± 10.9% vs 7.6% ± 9%; P < .001) and off-track lesions (23% vs 13%; P = .046) were higher in the ABR group, while preoperative GBL range was similar (0-42% vs 0-47%). Changes in the VAS (1.9 vs 0.9; P = .019) and WOSI (1096 vs 805; P < .001) were improved in ABR. The percentage of patients who achieved a minimal clinically important difference was improved in WOSI for ABR and PASS for ABR in SANE, VAS, and WOSI scores. The ABR cohort reported worse changes in external rotation (ER) (-4° vs +19°; P < .001). Return to sport among overhead and contact athletes favored ABR (91.5% vs 72.7%; P = .007). Satisfaction and recurrent dislocation were similar. Surgical complications were observed in 0% of ABR cases, compared to 5.9% in the Latarjet group.

Conclusion: Primary ABR resulted in 2-year functional outcomes that were as good or superior to primary Latarjet, with higher return to sport for overhead and contact activities, fewer complications, and comparably low recurrence rates, even despite greater bipolar bone loss in the ABR cohort. However, this comes at the expense of decreased external rotation, which may be considered in individual patients.

Level Of Evidence: III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2022.03.031DOI Listing
April 2022

The association between anterior shoulder joint capsule thickening and glenoid deformity in primary glenohumeral osteoarthritis.

J Shoulder Elbow Surg 2022 Mar 22. Epub 2022 Mar 22.

Midwest Orthopaedics at Rush, Rush University, Chicago, IL, USA.

Background: Anterior shoulder joint capsule thickening is typically present in osteoarthritic shoulders, but its association with specific patterns of glenoid wear is incompletely understood. We sought to determine the relationship between anterior capsular thickening and glenoid deformity in primary glenohumeral osteoarthritis.

Methods: We retrospectively identified 134 consecutive osteoarthritic shoulders with magnetic resonance imaging and computed tomography scans performed. Axial fat-suppressed magnetic resonance imaging slices were used to quantify the anterior capsular thickness in millimeters, measured at its thickest point below the subscapularis muscle. Computed tomography scans were used to classify glenoid deformity according to the Walch classification, and an automated 3-dimensional software program provided values for glenoid retroversion and humeral head subluxation. Multinomial and linear regression models were used to characterize the association of anterior capsular thickening with Walch glenoid type, glenoid retroversion, and posterior humeral head subluxation while controlling for patient age and sex.

Results: The anterior capsule was thickest in glenoid types B2 (5.5 mm, 95% confidence interval [CI]: 5.0-6.0) and B3 (6.1 mm, 95% CI: 5.6-6.6) and thinnest in A1 (3.7 mm, 95% CI: 3.3-4.2; P < .001). Adjusted for age and sex, glenoid types B2 (odds ratio: 4.4, 95% CI: 2.3-8.4, P < .001) and B3 (odds ratio: 5.4, 95% CI: 2.8-10.4, P < .001) showed the strongest association with increased anterior capsule thickness, compared to glenoid type A1. Increased capsular thickness correlated with greater glenoid retroversion (r = 0.57; P < .001) and posterior humeral head subluxation (r = 0.50; P < .001). In multivariable analysis, for every 1-mm increase in anterior capsular thickening, there was an adjusted mean increase of 3.2° (95% CI: 2.4-4.1) in glenoid retroversion and a 3.8% (95% CI: 2.7-5.0) increase in posterior humeral head subluxation.

Conclusions: Increased thickening of the anterior shoulder capsule is associated with greater posterior glenoid wear and humeral head subluxation. Additional research should determine whether anterior capsular disease plays a causative role in the etiology or progression of eccentric glenohumeral osteoarthritis.
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http://dx.doi.org/10.1016/j.jse.2022.02.011DOI Listing
March 2022

Adverse Events Associated With Robotic-Assisted Joint Arthroplasty: An Analysis of the US Food and Drug Administration MAUDE Database.

J Arthroplasty 2022 08 21;37(8):1526-1533. Epub 2022 Mar 21.

Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA.

Background: The use of robotic assistance in arthroplasty is increasing; however, the spectrum of adverse events potentially associated with this technology is unclear. Improved understanding of the causes of adverse events in robotic-assisted arthroplasty can prevent future incidents and enhance patient outcomes.

Methods: Adverse event reports to the US Food and Drug Administration Manufacturer and User Facility Device Experience database involving robotic-assisted total hip arthroplasty (THA), total knee arthroplasty (TKA), and partial knee arthroplasty were reviewed to determine causes of malfunction and related patient impact.

Results: Overall, 263 adverse event reports were included. The most frequently reported adverse events were unexpected robotic arm movement for TKA (59/204, 28.9%) and retained registration checkpoint for THA (19/44, 43.2%). There were 99 reports of surgical delay with an average delay of 20 minutes (range 1-120). Thirty-one cases reported conversion to manual surgery. In total, 68 patient injuries were reported, 7 of which required surgical reintervention. Femoral notching (12/36, 33.3%) was the most common for TKA and retained registration checkpoint (19/28, 67.9%) was the most common for THA. Although rare, additional reported injuries included femoral, tibial, and acetabular fractures, MCL laceration, additional retained foreign bodies, and an electrical burn.

Conclusion: Despite the increasing utilization of robotic-assisted arthroplasty in the United States, numerous adverse events are possible and technical difficulties experienced intraoperatively can result in prolonged surgical delays. The events reported herein seem to indicate that robotic-assisted arthroplasty is generally safe with only a few reported instances of serious complications, the nature of which seems more related to suboptimal surgical technique than technology. Based on our data, the practice of adding registration checkpoints and bone pins to the instrument count of all robotic-assisted TJA cases should be widely implemented to avoid unintended retained foreign objects.
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http://dx.doi.org/10.1016/j.arth.2022.03.060DOI Listing
August 2022

Performance Outcomes and Return to Sport Following Metacarpal Fractures in Major League Baseball Players.

Hand (N Y) 2022 Mar 21:15589447221081565. Epub 2022 Mar 21.

Newton-Wellesley Hospital, MA, USA.

Background: Major League Baseball (MLB) players are at risk for metacarpal fractures; however, little is known regarding the impact of these injuries on future performance. The purpose of this study was to determine whether MLB players who sustain metacarpal fractures demonstrate decreased performance on return to competition in comparison to the performance of control-matched peers.

Methods: Data for MLB position players with metacarpal fractures incurred over 17 seasons were obtained from injury reports, press releases, and player profiles. Age, position, career experience, body mass index (BMI), injury mechanism, handedness, and treatment were recorded. Individual season statistics for the 2 seasons immediately before injury and the 2 seasons after injury were obtained. Controls matched by player position, age, BMI, career experience, and performance statistics were identified. A performance comparison of the cohorts was performed.

Results: Overall, 24 players met inclusion criteria. Eleven players with metacarpal fractures were treated with surgery (46%) and 13 (54%) were treated nonoperatively. Players treated nonoperatively missed significantly fewer games following injury compared with those treated operatively (35.5 vs 52.6 games, = .04). There was no significant difference in postinjury performance when compared with preinjury performance among the fracture cohorts. Players with metacarpal fractures treated nonoperatively had a significant decline in their Wins Above Replacement (WAR) 2 seasons postinjury (1.37 point decline) in comparison to matched controls (0.84 point increase) ( = .02). There was no significant difference in WAR 1 or 2 seasons postinjury for players with metacarpal fractures treated operatively in comparison to the control cohort.

Conclusions: Major League Baseball players sustaining metacarpal fractures can expect to return to their preinjury performance levels following both nonoperative and operative treatment. However, players treated nonoperatively may witness a decline in their performance compared with peers over the long term. Orthopedic surgeons treating professional athletes with metacarpal fractures should consider these outcomes when counseling their patients and making treatment recommendations.
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http://dx.doi.org/10.1177/15589447221081565DOI Listing
March 2022

Substantial Inconsistency and Variability Exists Among Minimum Clinically Important Differences for Shoulder Arthroplasty Outcomes: A Systematic Review.

Clin Orthop Relat Res 2022 07 17;480(7):1371-1383. Epub 2022 Mar 17.

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA.

Background: As the value of patient-reported outcomes becomes increasingly recognized, minimum clinically important difference (MCID) thresholds have seen greater use in shoulder arthroplasty. However, MCIDs are unique to certain populations, and variation in the modes of calculation in this field may be of concern. With the growing utilization of MCIDs within the field and value-based care models, a detailed appraisal of the appropriateness of MCID use in the literature is necessary and has not been systematically reviewed.

Questions/purposes: We performed a systematic review of MCID quantification in existing studies on shoulder arthroplasty to answer the following questions: (1) What is the range of values reported for the MCID in commonly used shoulder arthroplasty patient-reported outcome measures (PROMs)? (2) What percentage of studies use previously existing MCIDs versus calculating a new MCID? (3) What techniques for calculating the MCID were used in studies where a new MCID was calculated?

Methods: The Embase, PubMed, and Ovid/MEDLINE databases were queried from December 2008 through December 2020 for total shoulder arthroplasty and reverse total shoulder arthroplasty articles reporting an MCID value for various PROMs. Two reviewers (DAK, MAM) independently screened articles for eligibility, specifically identifying articles that reported MCID values for PROMs after shoulder arthroplasty, and extracted data for analysis. Each study was classified into two categories: those referencing a previously defined MCID and those using a newly calculated MCID. Methods for determining the MCID for each study and the variability of reported MCIDs for each PROM were recorded. The number of patients, age, gender, BMI, length of follow-up, surgical indications, and surgical type were extracted for each article. Forty-three articles (16,408 patients) with a mean (range) follow-up of 20 months (0.75 to 68) met the inclusion criteria. The median (range) BMI of patients was 29.3 kg/m2 (28.0 to 32.2 kg/m2), and the median (range) age was 68 years (53 to 84). There were 17 unique PROMs with MCID values. Of the 112 MCIDs reported, the most common PROMs with MCIDs were the American Shoulder and Elbow Surgeons (ASES) (23% [26 of 112]), the Simple Shoulder Test (SST) (17% [19 of 112]), and the Constant (15% [17 of 112]).

Results: The ranges of MCID values for each PROM varied widely (ASES: 6.3 to 29.5; SST: 1.4 to 4.0; Constant: -0.3 to 12.8). Fifty-six percent (24 of 43) of studies used previously established MCIDs, with 46% (11 of 24) citing one study. Forty-four percent (19 of 43) of studies established new MCIDs, and the most common technique was anchor-based (37% [7 of 19]), followed by distribution (21% [4 of 19]).

Conclusion: There is substantial inconsistency and variability in the quantification and reporting of MCID values in shoulder arthroplasty studies. Many shoulder arthroplasty studies apply previously published MCID values with variable ranges of follow-up rather than calculating population-specific thresholds. The use of previously calculated MCIDs may be acceptable in specific situations; however, investigators should select an anchor-based MCID calculated from a patient population as similar as possible to their own. This practice is preferable to the use of distribution-approach MCID methods. Alternatively, authors may consider using substantial clinical benefit or patient-acceptable symptom state to assess outcomes after shoulder arthroplasty.

Clinical Relevance: Although MCIDs may provide a useful effect-size based alternative to the traditional p value, care must be taken to use an MCID that is appropriate for the particular patient population being studied.
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http://dx.doi.org/10.1097/CORR.0000000000002164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9191322PMC
July 2022

Twitter Mentions Influence Academic Citation Count of Shoulder and Elbow Surgery Publications.

Cureus 2022 Jan 31;14(1):e21762. Epub 2022 Jan 31.

Orthopedic Surgery, Monmouth Medical Center, Long Branch, USA.

Background Social media use among scholars and journals is growing and has augmented the academic impact of published articles in several areas of medicine. However, the influence of social media postings on academic citations of shoulder and elbow surgery publications is not known. In this study, we sought (1) to quantify the adoption of Twitter use for the dissemination of research publications by three prominent shoulder and elbow surgery journals and (2) to determine the correlation between Twitter mentions and academic citations in shoulder and elbow surgery publications. Methodology A total of 396 original research articles from three shoulder and elbow surgery journals (Journal of Shoulder and Elbow Surgery (JSES), Shoulder & Elbow, and JSES International) published in 2018 were assessed 34 to 45 months after print publication. For each article, the total number of Twitter mentions were obtained using Altmetric Bookmarklet and grouped into those tweeted by authors, an official outlet, or a third party. Article citation data was obtained using the Google Scholar search engine. Pearson correlation was used to determine the association between the number of Twitter mentions and citation count. Results Of all articles, 51% (202/396) had at least one Twitter mention. Of all Twitter mentions, 12.7% (367/2,879) occurred within the first week of online publication dates, while 51.5% (1,482/2,879) occurred between online and print publication dates. Articles mentioned on Twitter had 1.3-fold more Google Scholar citations (17.7 ± 15.2) than articles with no Twitter mentions (14.0 ± 15.7) (p = 0.017). The number of Twitter mentions had a weakly positive correlation with academic citation count (r = 0.25; p < 0.001). No significant difference in academic citation rates was found between articles tweeted by authors or official outlets when compared to articles tweeted by a third party only (p = 0.97 and p = 0.34, respectively). Conclusions Approximately half of shoulder and elbow surgery publications are shared on Twitter, with the majority of the activity occurring prior to their print publication date. The finding that tweeted articles have more academic citations within three years of release suggests that social media activity seems to amplify the academic impact of shoulder and elbow surgery publications.
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http://dx.doi.org/10.7759/cureus.21762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8889917PMC
January 2022

COVID-19 as a Catalyst for Same-Day Discharge Total Shoulder Arthroplasty.

J Clin Med 2021 Dec 16;10(24). Epub 2021 Dec 16.

Oregon Shoulder Institute at Southern Oregon Orthopedics, Medford, OR 97504, USA.

The COVID-19 pandemic caused major disruptions to the healthcare system, but its impact on the transition to same-day discharge shoulder arthroplasty remains unexplored. This study assessed the effect of COVID-19 on length of stay (LOS), same-day discharge rates, and other markers of resource use after elective total shoulder arthroplasty. A total of 508 consecutive patients undergoing elective primary total shoulder arthroplasty between 2019 and 2021 were identified and divided into 2 cohorts: "pre-COVID" (March 2019-March 2020; = 263) and "post-COVID" (May 2020-March 2021; = 245). No elective shoulder arthroplasties were performed at our practice between 18 March and 11 May 2020. Outcome measures included LOS, same-day discharge, discharge location, and 90-day emergency department (ED) visits, readmissions and reoperations. There were no significant differences in baseline preoperative patient characteristics. Shoulder arthroplasty performed post-COVID was associated with a shorter LOS (12 vs. 16 h, = 0.017) and a higher rate of same-day discharge (87.3 vs. 79.1%, = 0.013). The rate of discharge to skilled nursing facilities was similarly low between the groups (1.9 vs. 2.0%, = 0.915). There was a significant reduction in the rate of 90-day ED visits post-COVID (7.4 vs. 13.3%, = 0.029), while there were no differences in 90-day reoperation (2.0 vs. 1.5%, = 0.745) or readmission rates (1.2 vs. 1.9%, = 0.724). The COVID-19 pandemic seems to have accelerated the shift towards shorter stays and more same-day discharge shoulder arthroplasties, while reducing unexpected acute health needs (e.g., ED visits) without adversely affecting readmission and reoperation rates.
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http://dx.doi.org/10.3390/jcm10245908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8709337PMC
December 2021

JSES social media and visual abstracts.

J Shoulder Elbow Surg 2022 01 20;31(1). Epub 2021 Oct 20.

Rush University Medical Center, Chicago, IL, USA.

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http://dx.doi.org/10.1016/j.jse.2021.10.001DOI Listing
January 2022

Patient Perceptions of Telehealth Orthopedic Services in the Era of COVID-19 and Beyond.

Orthopedics 2021 Sep-Oct;44(5):e668-e674. Epub 2021 Sep 1.

The coronavirus disease 2019 (COVID-19) pandemic necessitated an unprecedented increase in the use of telehealth services in orthopedics. Patient attitudes toward and satisfaction with virtual orthopedic services remain largely unexplored. A prospective study of all orthopedic patients at a tertiary academic medical center who had a telehealth appointment between April 1, 2020, and May 5, 2020, was performed to assess patients' experience with a validated 21-item telehealth satisfaction questionnaire. The survey contained statements designed to assess patients' level of agreement with numerous aspects of telehealth, including convenience, the surgeon's ability to engage in care, ease of use, and future use of telehealth. Most respondents (86.7%) were satisfied with the telehealth system. The majority of patients expressed that the system is easy to use (90.0%), is convenient (86.7%), and saves them time (83.3%). Nearly all (95%) patients agreed that their surgeon could answer their questions with the use of this technology, although nearly half (46.6%) identified the lack of physical contact during the examination as problematic. Only 46.7% of patients agreed that telehealth should be a standard form of health care delivery in the future; these patients were found to have significantly longer commute times compared with those who did not (52.1±58.2 vs 28.3±19.2, =.03). Patient perspectives on the widespread adoption of telehealth, such as ease of use, privacy protection, and convenience, showed that these anticipated barriers may be some of the greatest advantages of telehealth. The COVID-19 pandemic may have provided the momentum for telehealth to become a mainstay of orthopedic health care delivery in the future. [. 2021;44(5):e668-e674.].
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http://dx.doi.org/10.3928/01477447-20210817-07DOI Listing
October 2021

Rotator cuff fatty infiltration and muscle atrophy: relation to glenoid deformity in primary glenohumeral osteoarthritis.

J Shoulder Elbow Surg 2022 Feb 12;31(2):286-293. Epub 2021 Aug 12.

Department of Orthopaedic Surgery, New England Baptist Hospital, Tufts University School of Medicine, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA. Electronic address:

Background: Muscle atrophy (MA) and fatty infiltration (FI) are degenerative processes of the rotator cuff musculature that have incompletely understood relationships with the development of eccentric glenoid wear in the setting of primary glenohumeral osteoarthritis (GHOA).

Methods: All patients with GHOA and an intact rotator cuff who underwent both magnetic resonance imaging and computed tomography scans of the affected shoulder prior to total shoulder arthroplasty between 2015 and 2020 were identified from a prospectively maintained registry. Rotator cuff MA was measured quantitatively on sequential sagittal magnetic resonance images, whereas FI was assessed on sagittal magnetic resonance imaging slices using the Goutallier classification. Preoperative computed tomography scans were reconstructed using automated 3-dimensional software to determine glenoid retroversion, glenoid inclination, and humeral head subluxation. Glenoid deformity was classified according to the Walch classification. Univariate and multivariable regression analyses were performed to characterize associations between age, sex, muscle area, FI, and glenoid morphology.

Results: Among the 127 included patients, significant associations were found between male sex and larger overall rotator cuff musculature (P < .01), increased ratio of the posterior rotator cuff (PRC) to the subscapularis area (P = .01), and glenoid retroversion (19° vs. 14°, P < .01). Larger supraspinatus and PRC muscle size was correlated with increased retroversion (r = 0.23 [P = .006] for supraspinatus and r = 0.25 [P = .004] for PRC) and humeral head subluxation (r = 0.25 [P = .004] for supraspinatus and r = 0.28 [P = .001] for PRC). The ratio of PRC muscle size to anterior rotator cuff muscle size was not associated with evidence of eccentric glenoid wear (P > .05). After we controlled for confounding factors, increasing glenoid retroversion was associated with high-grade infraspinatus FI (β, 6.8; 95% confidence interval, 2.9-10.7; P < .01) whereas larger PRC musculature was predictive of a Walch type B (vs. type A) glenoid (odds ratio, 1.3; 95% confidence interval, 1.0-1.5; P = .04).

Conclusion: Patients with eccentric glenoid wear in the setting of primary GHOA and an intact rotator cuff appear to have both larger PRC musculature and higher rates of infraspinatus FI. Although the temporal and causal relationships of these associations remain ambiguous, MA and FI should be considered 2 discrete processes in the natural history of GHOA.
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http://dx.doi.org/10.1016/j.jse.2021.07.007DOI Listing
February 2022

Wide variability of shoulder and elbow case volume in orthopedic surgery residency.

J Shoulder Elbow Surg 2022 Feb 3;31(2):437-444. Epub 2021 Aug 3.

Professional Orthopedic Associates, Tinton Falls, NJ, USA.

Background: Despite the growing popularity of certain shoulder and elbow procedures (eg, shoulder arthroplasty), resident exposure to these surgeries remains unclear. This study sought to evaluate trends in graduating orthopedic resident case volumes of commonly performed shoulder and elbow procedures.

Methods: The Accreditation Council for Graduate Medical Education (ACGME) surgical case log data from 2016 to 2020 for graduating US orthopedic surgery residents was assessed. Procedures of the shoulder and humerus/elbow were categorized into predefined ACGME categories: repair/revision/reconstruction, fracture/dislocation, and arthroscopy. The average number of cases performed per resident in each of these categories was directly compared from 2016 to 2020. The 10th and 90th percentiles of case volumes within each category of procedures was compared from 2016 and 2020.

Results: There was a 31% increase in the number of shoulder repair/revision/reconstruction cases between 2016 and 2020 (average: 27.5 to 36.1; P < .001), followed by a 23% increase for elbow fracture/dislocation (24.4 to 30; P < .001), 21% increase for elbow repair/revision/reconstruction (10.6 to 12.8; P < .001), and 16% increase for shoulder arthroscopy (69 to 79.7; P < .001). No significant changes were found for shoulder fracture/dislocation and elbow arthroscopy. There was a wide case volume variability for each procedure, particularly for shoulder repair/revision/reconstruction, where there was a nearly 5-fold difference in the number of cases performed between the 10th and 90th percentiles of residents in 2020 (13 vs. 62 cases, respectively).

Conclusions: The case category shoulder repair/revision/reconstruction has seen the largest relative increase in the shoulder and elbow case volume of graduating orthopedic surgery residents, most likely reflecting the national rising trends of shoulder arthroplasty. However, our study shows that there is wide variability in resident exposure to these cases. Implementation of shoulder arthroplasty case minimum requirements might help reduce case variability and discrepancies in resident education.
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http://dx.doi.org/10.1016/j.jse.2021.06.023DOI Listing
February 2022

Area Deprivation Index and Magnitude of Scoliosis at Presentation to a Tertiary Referral Scoliosis Clinic in Massachusetts.

J Pediatr Orthop 2021 Oct;41(9):e712-e716

Department of Orthopaedic Surgery, Tufts Children's Hospital, Tufts University School of Medicine, Boston, MA.

Background: There is growing interest in identifying predictors of large scoliosis curves at initial presentation, but few data to guide such preventive efforts. The association of neighborhood socioeconomic deprivation with curve magnitude in this context has not been previously evaluated. The purpose of our study was to determine the correlation of socioeconomic deprivation with scoliosis curve magnitude at initial presentation. Secondarily, we assessed the correlation of body mass index (BMI) with curve severity.

Methods: We retrospectively identified 202 patients presenting with adolescent idiopathic scoliosis to a single tertiary care center in Massachusetts from January 2015 to August 2018. The Area Deprivation Index (ADI), a validated composite measure of neighborhood socioeconomic deprivation, was calculated for each patient. Curve magnitude, age, sex, BMI, race, and insurance status were recorded. Pearson correlation was used to determine the association of the ADI and BMI with scoliosis severity.

Results: There was no correlation between the ADI and the magnitude of scoliosis at presentation (r=0.055; P=0.43). Greater BMI was moderately correlated with increased scoliosis curve magnitude (r=0.28; P<0.001). There was no association between curve magnitude and patient age, sex, race, or insurance status.

Conclusions: The finding that neighborhood socioeconomic deprivation did not correlate with greater scoliosis severity at presentation may be suggestive of equitable access to specialized scoliosis care. Future research should determine whether this reassuring finding is unique to Massachusetts--a state with high rates of health insurance coverage--or generalizable to other US states. In addition, our study further corroborates the notion that greater BMI is associated with larger scoliosis curves, and calls for targeted interventions to facilitate early scoliosis detection in the growing childhood obese population.

Level Of Evidence: Level II-prognostic study and retrospective study.
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http://dx.doi.org/10.1097/BPO.0000000000001869DOI Listing
October 2021

A break-even analysis of tranexamic acid for prevention of periprosthetic joint infection following total hip and knee arthroplasty.

J Orthop 2021 Jul-Aug;26:54-57. Epub 2021 Jul 13.

Tufts Medical Center, Boston, MA, USA.

Purpose: Despite the commonplace use of tranexamic acid in total joint arthroplasty, much of the current data regarding its cost-effectiveness examines savings directly related to its hemostatic properties, without considering its protective effect against periprosthetic joint infections. Using break-even economic modeling, we calculated the cost-effectiveness of routine tranexamic acid administration for infection prevention in total joint arthroplasty.

Materials And Methods: The cost of intraoperative intravenous tranexamic acid, the cost of revision arthroplasty for periprosthetic joint infections, and the baseline rates of periprosthetic joint infections in patients who did not receive intraoperative tranexamic acid were obtained from the literature and institutional purchasing records. Break-even economic modeling incorporating these variables was performed to determine the absolute risk reduction in infection rate to make routine intraoperative tranexamic acid use economically justified. The number needed to treat was calculated from the absolute risk reduction.

Results: Routine use of intraoperative tranexamic acid is economically justified if it prevents at least 1 infection out of 3125 total joint arthroplasties (absolute risk reduction = 0.032%). Cost-effectiveness was maintained with varying costs of tranexamic acid, infection rates, and periprosthetic joint infection costs.

Conclusion: The routine use of intraoperative tranexamic acid is a highly cost-effective practice for infection prevention in primary and revision total joint arthroplasty. The use of tranexamic acid is warranted across a wide range of costs of tranexamic acid, initial infection rates, and costs of periprosthetic joint infection treatment.
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http://dx.doi.org/10.1016/j.jor.2021.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8283265PMC
July 2021

Gross Trunnion Failure of a Type 1 Taper After Metal-on-Polyethylene Total Hip Arthroplasty: A Report of 2 Cases.

JBJS Case Connect 2021 06 24;11(2). Epub 2021 Jun 24.

Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts.

Case: We describe 2 cases of gross trunnion failure (GTF) in males with Centers for Disease Control and Prevention Class 3 obesity 10 years after metal-on-polyethylene total hip arthroplasty (THA) with a titanium-alloy femoral stem and Type 1 taper. One patient received a large diameter cobalt-chromium femoral head, whereas the other received a smaller diameter head, both with high-offset femoral stems.

Conclusion: This is the first report of GTF involving the Echo Bi-Metric femoral stem after metal-on-polyethylene THA, and surgeons should consider the potential complication of GTF when using this specific femoral stem with metal heads in obese male patients.
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http://dx.doi.org/10.2106/JBJS.CC.21.00098DOI Listing
June 2021
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