Publications by authors named "Tally Lassiter"

21 Publications

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Early aseptic reoperation after shoulder arthroplasty increases risk of subsequent prosthetic joint infection.

JSES Int 2021 Nov 5;5(6):1067-1071. Epub 2021 Aug 5.

Duke University Medical Center, Durham, NC, USA.

Background: Despite the success of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), the clinical course of some patients necessitates operative intervention in the acute postoperative period. In this study, we evaluate the risk of subsequent prosthetic joint infection (PJI) in patients who undergo an aseptic reoperation within 90 days of primary shoulder arthroplasty.

Method: A retrospective review of patients with primary TSA and RSA was performed using a commercially available national database (PearlDiver Inc., Fort Wayne, IN, USA). Queries were performed with use of International Classification of Diseases, Ninth Revision and Tenth Revision and Current Procedural Technology codes. Patients were divided into cohorts based on undergoing aseptic reoperation, reoperation for PJI, or no reoperations within 90 days of index procedure. Primary outcome was subsequent PJI within 1 year of index procedure. Observed PJI rates were compared using chi-square analysis. Risk factors for PJI were compared using logistic regression.

Results: From 2010 to 2018, a total of 96,648 patients underwent primary shoulder arthroplasty: 46,810 underwent TSA and 49,838 underwent RSA. The rate of aseptic reoperation within 90 days was 0.72% and 1.5% in the TSA and RSA cohorts, respectively. At 1 year postoperatively, patients who underwent an aseptic reoperation within 90 days had an elevated risk of subsequent PJI compared with the overall rate of PJI in the TSA (3.54% vs. 0.75%;  < .001) and RSA (3.08% vs. 0.73%;  < .001) cohorts. On multivariate logistic regression analysis, aseptic reoperation within 90 days was identified as a significant risk factor for subsequent PJI in the TSA cohort (odds ratio, 14.19;  < .001) and RSA cohort (odds ratio, 8.38;  < .001). The most common indication for aseptic reoperation was postoperative prosthetic joint instability in both the TSA (31%) and RSA (49%) cohorts.

Conclusion: Aseptic reoperation within 90 days of primary TSA or primary RSA was associated with a notably increased risk of subsequent PJI.
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http://dx.doi.org/10.1016/j.jseint.2021.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8568807PMC
November 2021

Intraoperative fractures in shoulder arthroplasty: risk factors and outcomes.

JSES Int 2021 Nov 14;5(6):1021-1026. Epub 2021 Sep 14.

Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.

Background: The incidence of shoulder arthroplasty in the United States continues to increase, and while the risk of intraoperative complications such as fracture remains relatively low, there has been little investigation into whether certain patient-specific risk factors predispose to this complication. This study characterizes the incidence of intraoperative fracture during shoulder arthroplasty and additionally hypothesizes that certain risk factors may exist in addition to potentially leading to worsened near-term outcomes.

Methods: An institutional database of shoulder arthroplasties (N = 1773; 994 anatomic, 779 reverse) was retrospectively reviewed, and the operative reports for each case were examined for documentation of an intraoperative fracture, including during which surgical step the fracture took place. Various preoperative and intraoperative factors were tested for comparative significance ( < .05) using chi-square and Kruskal-Wallis tests as appropriate. Length of stay, 90-day readmission, and discharge to rehabilitation or skilled nursing facility (SNF) were further examined as secondary outcomes.

Results: Twenty-one (1.2%) intraoperative fractures were documented, a majority of which occurred in reverse shoulder arthroplasties compared to anatomic procedures (overall incidence: 2.5% vs. 0.2%,  < .001). These most commonly occurred during either stem broaching (33%) or seating (33%) and were most likely to involve the metaphysis (53%) or greater tuberosity (33%). Five fractures occurred during revision arthroplasty, while 16 fractures occurred during primary procedures (overall incidence: 3.0 vs. 1.0%,  = .03). Patient factors reaching statistical significance included female gender and liver disease, while age and smoking history were notably not associated with intraoperative fracture. The fracture cohort had a significantly longer mean length of stay (2.42 vs. 2.17 days,  < .001). While the rates of 90-day readmission and discharge to SNF/rehab were higher in the fracture cohort, these values did not reach statistical significance.

Conclusion: Intraoperative fractures are a rare complication (1.2%) in shoulder arthroplasty, with reverse shoulder arthroplasty, revision cases, and female gender associated with an elevated overall risk. While these patients had a longer inpatient hospitalization, the substantially higher rates of 90-day readmission and discharge to SNF/rehab did not reach significance in our limited institutional cohort. The aforementioned incidence and risk factors serve as crucial evidence for use during the preoperative counseling process with patients as part of a shared decision-making model.
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http://dx.doi.org/10.1016/j.jseint.2021.07.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8569010PMC
November 2021

A Validated Pre-Operative Risk Prediction Tool For Discharge to Skilled Nursing or Rehabilitation Facility Following Anatomic or Reverse Shoulder Arthroplasty.

J Shoulder Elbow Surg 2021 Oct 23. Epub 2021 Oct 23.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA.

Background: As bundled payment models continue spread, understanding the primary drivers of cost excess helps providers avoid penalties and ensure equal healthcare access. Recent work has shown discharge to rehabilitation and skilled nursing facilities (SNF) to be a primary cost driver in total joint arthroplasty, and an accurate preoperative risk calculator for shoulder arthroplasty would not only help counsel patients in clinic during shared decision-making conversations, but also identify high-risk individuals who may benefit from preoperative optimization and discharge planning.

Methods: Shoulder arthroplasty cohorts from two geographically diverse, high-volume centers were reviewed, including 1,773 cases from Institution #1 (56% anatomic) and 3,637 from Institution #2 (50% anatomic). The predictive ability of a variety of candidate variables for discharge to SNF/rehab was tested, including case type, sociodemographic factors, and the 30 Elixhauser comorbidities. Variables surviving parameter selection were incorporated into a multivariable logistic regression model built from Institution #1's cohort, with accuracy then validated using Institution #2's cohort.

Results: 485 (9%) shoulder arthroplasties overall were discharged to post-acute care (anatomic: 6%, reverse: 14%, p < 0.0001), and these patients had significantly higher rates of unplanned 90-day readmission (5% vs 3%, p = 0.0492). Cases performed for preoperative fracture were more likely to require post-acute care (13% vs 3%, p < 0.0001), while revision cases were not (10% vs 10%, p = 0.8015). A multivariable logistic regression model derived from the Institution #1 cohort demonstrated excellent preliminary accuracy (AUC: 0.87), requiring only 11 preoperative variables (in order of importance): age, marital status, fracture, neurologic disease, paralysis, ASA, gender, electrolyte disorder, chronic pulmonary disease, diabetes, and coagulation deficiency. This model performed exceptionally well during external validation using the Institution #2 cohort (AUC: 0.84), and to facilitate convenient use was incorporated into a freely-available, online prediction tool. A model built using the combined cohort demonstrated even higher accuracy (AUC: 0.89).

Conclusions: This validated preoperative clinical decision tool reaches excellent predictive accuracy for discharge to SNF/rehab following shoulder arthroplasty, providing a vital tool for both patient counseling and preoperative discharge planning. Further, model parameters should form the basis for reimbursement legislation adjusting for patient comorbidities, ensuring no disparities in access arise for at-risk populations.

Level Of Evidence: Level III; Retrospective Case Control Design; Prognosis Study.
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http://dx.doi.org/10.1016/j.jse.2021.10.009DOI Listing
October 2021

Appropriate patient selection for outpatient shoulder arthroplasty: a risk prediction tool.

J Shoulder Elbow Surg 2021 Sep 27. Epub 2021 Sep 27.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: The transition from inpatient to outpatient shoulder arthroplasty critically depends on appropriate patient selection, both to ensure safety and to counsel patients preoperatively regarding individualized risk. Cost and patient demand for same-day discharge have encouraged this transition, and a validated predictive tool may help decrease surgeon liability for complications and help select patients appropriate for same-day discharge. We hypothesized that an accurate predictive model could be created for short inpatient length of stay (discharge at least by postoperative day 1), potentially serving as a useful proxy for identifying patients appropriate for true outpatient shoulder arthroplasty.

Methods: A multicenter cohort of 5410 shoulder arthroplasties (2805 anatomic and 2605 reverse shoulder arthroplasties) from 2 geographically diverse, high-volume health systems was reviewed. Short inpatient stay was the primary outcome, defined as discharge on either postoperative day 0 or 1, and 49 patient outcomes and factors including the Elixhauser Comorbidity Index, sociodemographic factors, and intraoperative parameters were examined as candidate predictors for a short stay. Factors surviving parameter selection were incorporated into a multivariable logistic regression model, which underwent internal validation using 10,000 bootstrapped samples.

Results: In total, 2238 patients (41.4%) were discharged at least by postoperative day 1, with no difference in rates of 90-day readmission (3.5% vs. 3.3%, P = .774) between cohorts with a short length of stay and an extended length of stay (discharge after postoperative day 1). A multivariable logistic regression model demonstrated high accuracy (area under the receiver operator characteristic curve, 0.762) for discharge by postoperative day 1 and was composed of 13 variables: surgery duration, age, sex, electrolyte disorder, marital status, American Society of Anesthesiologists score, paralysis, diabetes, neurologic disease, peripheral vascular disease, pulmonary circulation disease, cardiac arrhythmia, and coagulation deficiency. The percentage cutoff maximizing sensitivity and specificity was calculated to be 47%. Internal validation showed minimal loss of accuracy after bias correction for overfitting, and the predictive model was incorporated into a freely available online tool to facilitate easy clinical use.

Conclusions: A risk prediction tool for short inpatient length of stay after shoulder arthroplasty reaches very good accuracy despite requiring only 13 variables and was derived from an underlying database with broad geographic diversity in the largest institutional shoulder arthroplasty cohort published to date. Short inpatient length of stay may serve as a proxy for identifying patients appropriate for same-day discharge, although perioperative care decisions should always be made on an individualized and holistic basis.
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http://dx.doi.org/10.1016/j.jse.2021.08.023DOI Listing
September 2021

Characteristics and risk factors for 90-day readmission following shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Aug 25. Epub 2021 Aug 25.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA. Electronic address:

Background: Anatomic total shoulder arthroplasty (TSA) and reverse TSA are the standard of care for end-stage shoulder arthritis. Advancements in implant design, perioperative management, and patient selection have allowed shorter inpatient admissions. Unplanned readmissions remain a significant complication. Identification of risk factors for readmission is prudent as physicians and payers prepare for the adoption of bundled care reimbursement models. The purpose of this study was to identify characteristics and risk factors associated with readmission following shoulder arthroplasty using a large, bi-institutional cohort.

Methods: A total of 2805 anatomic TSAs and 2605 reverse TSAs drawn from 2 geographically diverse, tertiary health systems were examined for unplanned inpatient readmissions within 90 days following the index operation (primary outcome). Forty preoperative patient sociodemographic and comorbidity factors were tested for their significance using both univariable and multivariable logistic regression models, and backward stepwise elimination selected for the most important associations for 90-day readmission. Readmissions were characterized as either medical or surgical, and subgroup analysis was performed. A short length of stay (discharge by postoperative day 1) and discharge to a rehabilitation or skilled nursing facility were also examined as secondary outcomes. Parameters associated with increased readmission risk were included in a predictive model.

Results: Within 90 days of surgery, 175 patients (3.2%) experienced an unanticipated readmission, with no significant difference between institutions (P = .447). There were more readmissions for surgical complications than for medical complications (62.9% vs. 37.1%, P < .001). Patients discharged to a rehabilitation or skilled nursing facility were significantly more likely to be readmitted (13.1% vs. 8.8%, P = .049), but a short inpatient length of stay was not associated with an increased rate of 90-day readmission (42.9% vs. 41.3%, P = .684). Parameter selection based on predictive ability resulted in a multivariable logistic regression model composed of 16 preoperative patient factors, including reverse TSA, revision surgery, right-sided surgery, and various comorbidities. The area under the receiver operator characteristic curve for this multivariable logistic regression model was 0.716.

Conclusion: Risk factors for unplanned 90-day readmission following shoulder arthroplasty include reverse shoulder arthroplasty, surgery for revision and fracture, and right-sided surgery. Additionally, there are several modifiable and nonmodifiable risk factors that can be used to ascertain a patient's readmission probability. A shorter inpatient stay is not associated with an increased risk of readmission, whereas discharge to post-acute care facilities does impose a greater risk of readmission. As scrutiny around health care cost increases, identifying and addressing risk factors for readmission following shoulder arthroplasty will become increasingly important.
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http://dx.doi.org/10.1016/j.jse.2021.07.017DOI Listing
August 2021

The Efficacy of Peroxide Solutions in Decreasing Cutibacterium acnes Burden Around the Shoulder.

J Am Acad Orthop Surg 2021 Aug 25. Epub 2021 Aug 25.

From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.

Background: Cutibacterium acnes is a common pathogen associated with surgical site infection after shoulder surgery; current standard of care products are largely ineffective at reducing C acnes bacterial burden before surgery. The purpose of this systematic meta-analysis was to assess the efficacy of peroxide-containing solutions (PCS) in decreasing the C acnes burden on the shoulder.

Methods: This was a systematic review of all level I and II studies investigating the effect of peroxidase-containing products for skin preparation. We extracted data regarding demographics, treatment details and timing, study methodology, and culture positivity. Forest plots were used to determine the pooled efficacy of peroxide solutions versus control.

Results: Seven studies with 412 patients were eligible for inclusion. Notable heterogeneity was observed in the manner and timing of peroxide application. Two studies applied PCS at the time of surgery; four studies applied PCS in the 24- to 72-hour period leading up to culture acquisition. Compared with the placebo, peroxide significantly diminished C acnes culture positivity (Hazard Ratio 0.174, P = 0.009). When considering using peroxide-containing products in the period leading up to surgery or at the time of surgery, in addition to standard preparation, the addition of peroxide significantly diminished C acnes culture positivity (HR 0.467, P = 0.004). Owing to study heterogeneity, we could not make notable comparisons based on the timing or duration of benzoyl peroxides application.

Conclusions: Despite heterogeneity in study design, pooled results of high-quality data suggest that the addition of PCS can markedly reduce C acnes bioburden. This review was not able to identify the ideal regimen for the utilization of PCS for reduction of C acnes burden.

Level Of Evidence: Level II.
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http://dx.doi.org/10.5435/JAAOS-D-21-00457DOI Listing
August 2021

Short stay after shoulder arthroplasty does not increase 90-day readmissions in Medicare patients compared with privately insured patients.

J Shoulder Elbow Surg 2021 Jun 9. Epub 2021 Jun 9.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: As of January 1, 2021, total shoulder arthroplasty was removed from the Medicare inpatient-only list, reflecting a growing belief in the potential merits of same-day discharge regardless of insurance type. It is yet unknown whether Medicare populations, which frequently have more severe comorbidity burdens, would experience higher complication rates relative to privately insured patients, who are often younger with fewer comorbidities. Given the limited number of true outpatient cohorts available to study, discharge at least by postoperative day 1 may serve as a useful proxy for true same-day discharge, and we hypothesized that these Medicare patients would have increased 90-day readmission rates compared with their privately insured counterparts.

Methods: Data on 4723 total shoulder arthroplasties (anatomic in 2459 and reverse in 2264) from 2 large, geographically diverse health systems in patients having either Medicare or private insurance were collected. The unplanned 90-day readmission rate was the primary outcome, and patients were stratified into those who were discharged at least by postoperative day 1 (short inpatient stay) and those who were not. Patients with private insurance (n = 1845) were directly compared with those with Medicare (n = 2878), whereas cohorts of workers' compensation (n = 198) and Medicaid (n = 58) patients were analyzed separately. Forty preoperative variables were examined to compare overall health burden, with the χ and Wilcoxon rank sum tests used to test for statistical significance.

Results: Medicare patients undergoing short-stay shoulder arthroplasty were not significantly more likely than those with private insurance to experience an unplanned 90-day readmission (3.6% vs. 2.5%, P = .14). This similarity existed despite a substantially worse comorbidity burden in the Medicare population (P < .05 for 26 of 40 factors). Furthermore, a short inpatient stay did not result in an increased 90-day readmission rate in either Medicare patients (3.6% vs. 3.4%, P = .77) or their privately insured counterparts (2.5% vs. 2.4%, P = .92). Notably, when the analysis was restricted to a single insurance type, readmission rates were significantly higher for reverse shoulder arthroplasty compared with total shoulder arthroplasty (P < .001 for both), but when the analysis was restricted to a single procedure (anatomic or reverse), readmission rates were similar between Medicare and privately insured patients, whether undergoing a short or extended length of stay.

Conclusions: Despite a substantially more severe comorbidity profile, Medicare patients undergoing short-stay shoulder arthroplasty did not experience a significantly higher rate of unplanned 90-day readmission relative to privately insured patients. A higher incidence of reverse shoulder arthroplasty in Medicare patients does increase their overall readmission rate, but a similar increase also appears in privately-insured patients undergoing a reverse indicating that Medicare populations may be similarly appropriate for accelerated-care pathways.
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http://dx.doi.org/10.1016/j.jse.2021.05.013DOI Listing
June 2021

Malnutrition in elective shoulder arthroplasty: a multi-institutional retrospective study of preoperative albumin and adverse outcomes.

J Shoulder Elbow Surg 2021 Nov 2;30(11):2491-2497. Epub 2021 Apr 2.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA. Electronic address:

Background: Malnutrition is associated with poor postoperative outcomes after knee, hip, and spine surgery. However, whether albumin labs should be part of the routine preoperative workup for shoulder arthroplasty remains understudied. This study investigated the role of preoperative albumin levels in predicting common postoperative adverse outcomes in patients undergoing shoulder arthroplasty.

Methods: All shoulder arthroplasty cases performed at 2 tertiary referral centers between July 2013 and May 2019 (institution 1) and between June 2007 and Feb 2020 (institution 2) were reviewed. A total of 421 primary and 71 revision elective shoulder arthroplasty cases had preoperative albumin levels recorded. Common demographic variables and relevant Elixhauser comorbidities were pulled. Outcomes gathered included extended (>3 days) postoperative inpatient length of stay (eLOS), 90-day readmission, and discharge to rehab or skilled nursing facility (SNF).

Results: The prevalence of malnutrition (albumin <3.5 g/dL) was higher in the revision group compared with the primary group (36.6% vs. 19.5%, P = .001). Reverse shoulder arthroplasty (P = .013) and increasing American Society of Anesthesiologists score (P = .016) were identified as independent risk factors for malnutrition in the primary group. In the revision group, liver disease was associated with malnutrition (P = .046). Malnourished primary shoulder arthroplasty patients had an increased incidence of eLOS (26.8% vs. 13.6%, P = .003) and discharge to rehab/SNF (18.3% vs. 10.3%, P = .045). On univariable analysis, low albumin had an odds ratio (OR) of 2.34 for eLOS (P = .004), which retained significance in a multivariable model including age, American Society of Anesthesiologists score, sex, and body mass index (OR 2.11, P = .03). On univariable analysis, low albumin had an OR of 1.94 for discharge to SNF/rehab (P = .048), but this did not reach significance in the multivariable model. Among revisions, malnourished patients had an increased incidence of eLOS (30.8% vs. 6.7%, P = .014) and discharge to rehab/SNF (26.9% vs. 4.4%, P = .010). In both the primary and revision groups, there was no difference in 90-day readmission rate between patients with low or normal albumin.

Conclusion: Malnutrition is more prevalent among revision shoulder arthroplasty patients compared with those undergoing a primary procedure. Primary shoulder arthroplasty patients with low preoperative albumin levels have an increased risk of eLOS and may have an increased need for postacute care. Low albumin was not associated with a risk of 90-day readmissions. Albumin level merits further investigation in large, prospective cohorts to clearly define its role in preoperative risk stratification.
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http://dx.doi.org/10.1016/j.jse.2021.03.143DOI Listing
November 2021

Malpractice trends in shoulder and elbow surgery.

J Shoulder Elbow Surg 2021 Sep 3;30(9):2007-2013. Epub 2021 Feb 3.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Medical malpractice is a very common occurrence that many medical providers will have to face; approximately 17,000 medical malpractice cases are filed in the United States each year, and more than 99% of all surgeons are faced with at least 1 instance of malpractice litigation throughout their careers. Malpractice litigation also carries a major economic weight, with medical malpractice spending resulting in an aggregate expenditure of nearly $60 billion annually in the United States. Orthopedic surgery is one of the most common subspecialties involved in malpractice claims. Currently, there are no comprehensive studies examining malpractice lawsuits within shoulder and elbow surgery. Therefore, the purpose of this work is to examine trends in malpractice claims in shoulder and elbow surgery.

Methods: The Westlaw online legal database was queried in order to identify state and federal jury verdicts and settlements pertaining to shoulder and elbow surgery from 2010-2020. Only cases involving medical malpractice in which an orthopedic shoulder and elbow surgeon was a named defendant were included for analysis. All available details pertaining to the cases were collected. This included plaintiff demographic and geographic data. Details regarding the cases were also collected, such as anatomic location, pathology, complications, and case outcomes.

Results: Twenty-five malpractice lawsuits pertaining to orthopedic shoulder and elbow surgery were identified. Most plaintiffs in these cases were adult men, and the majority of cases were filed in the Southwest (28%) and Midwest (28%) regions of the United States. The most common anatomic region involved in claims was the rotator cuff (32%), followed by the glenohumeral joint (20%). The majority of these claims involved surgery (56%). Pain of mechanical nature was the most common complication seen in claims (56%). The jury ruled in favor of the defendant surgeon in most cases (80%).

Discussion: This is the first study that comprehensively examines the full scope of orthopedic shoulder and elbow malpractice claims across the United States. The most common complaint that plaintiffs reported at the time of litigation was residual pain after treatment due to a mechanical etiology, followed by complaints of nerve damage. A large portion of claims resulted after nonoperative treatment. A better understanding of the trends within malpractice claims is crucial to developing strategies for prevention.
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http://dx.doi.org/10.1016/j.jse.2020.12.018DOI Listing
September 2021

Distribution of Bone Contusion Patterns in Acute Noncontact Anterior Cruciate Ligament-Torn Knees.

Am J Sports Med 2021 02 7;49(2):404-409. Epub 2021 Jan 7.

Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.

Background: Bone contusions are commonly observed on magnetic resonance imaging (MRI) in individuals who have sustained a noncontact anterior cruciate ligament (ACL) injury. Time from injury to image acquisition affects the ability to visualize these bone contusions, as contusions resolve with time.

Purpose: To quantify the number of bone contusions and their locations (lateral tibial plateau [LTP], lateral femoral condyle [LFC], medial tibial plateau [MTP], and medial femoral condyle [MFC]) observed on MRI scans of noncontact ACL-injured knees acquired within 6 weeks of injury.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: We retrospectively reviewed clinic notes, operative notes, and imaging of 136 patients undergoing ACL reconstruction. The following exclusion criteria were applied: MRI scans acquired beyond 6 weeks after injury, contact ACL injury, and previous knee trauma. Fat-suppressed fast spin-echo T2-weighted MRI scans were reviewed by a blinded musculoskeletal radiologist. The number of contusions and their locations (LTP, LFC, MTP, and MFC) were recorded.

Results: Contusions were observed in 135 of 136 patients. Eight patients (6%) had 1 contusion, 39 (29%) had 2, 41 (30%) had 3, and 47 (35%) had 4. The most common contusion patterns within each of these groups were 6 (75%) with LTP for 1 contusion, 29 (74%) with LTP/LFC for 2 contusions, 33 (80%) with LTP/LFC/MTP for 3 contusions, and 47 (100%) with LTP/LFC/MTP/MFC for 4 contusions. No sex differences were detected in contusion frequency in the 4 locations ( > .05). Among the participants, 50 (37%) had medial meniscal tears and 52 (38%) had lateral meniscal tears.

Conclusion: The most common contusion patterns observed were 4 locations (LTP/LFC/MTP/MFC) and 3 locations (LTP/LFC/MTP).
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http://dx.doi.org/10.1177/0363546520981569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214466PMC
February 2021

Rotator cuff to deltoid and pectoralis tendon to anatomic neck distances: methods for anatomic restoration of humeral height and tuberosity position in proximal humerus fractures for operative fixation and arthroplasty.

JSES Int 2020 Dec 26;4(4):869-874. Epub 2020 Aug 26.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Introduction: Proper anatomic tuberosity reduction and restoration of humeral height during surgical treatment of proximal humerus fractures leads to fewer complications and better outcomes. In the presence of significant displacement and comminution in proximal humerus fractures, the assessment of the correct tuberosity position and humeral height can be challenging. The goal of this cadaveric study was to provide new and useful measurements for intraoperative guidance of proper tuberosity position and humeral height when treating proximal humerus fractures with open reduction internal fixation, anatomic hemiarthroplasty, or reverse total shoulder arthroplasty.

Methods: A total of 28 cadaveric shoulders were dissected with a deltopectoral approach. The distance between the insertion of the supraspinatus tendon and the superior aspect of the deltoid tendon was measured (cuff to deltoid distance [CDD]). Secondly, the distance between the superior aspects of the pectoralis major tendon to the medial aspect of the anatomic neck (PND) was measured. Further, we sought to determine if these measurements would correlate to patient height and differ between gender.

Results: The average age of the donors was 65.3 years (64% male). The CDD and PND were 87.6 ± 10.6 and 16.6 ± 6.9 mm, respectively (mean ± standard deviation). There were no differences between females and males for the CDD (86.9 ± 9.4 vs. 87.2 ± 15.2 mm,  = .96) and PND (16.3 ± 9.1 vs. 17.1 ± 5.9 mm,  = .76). There was no correlation between the cadaver height and CDD (R2 = 0.1) and PND (R2 = 0.3).

Discussion: In this study, we describe 2 new measurement tools that can readily be applied intraoperatively during surgical treatment of proximal humerus fractures to aid in tuberosity reduction and humeral height assessment. These measurements were found to be independent of patient height and gender and can be used as a reference tool for most patients.
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http://dx.doi.org/10.1016/j.jseint.2020.07.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738573PMC
December 2020

Comparison of the accuracy of telehealth examination versus clinical examination in the detection of shoulder pathology.

J Shoulder Elbow Surg 2021 May 29;30(5):1042-1052. Epub 2020 Aug 29.

Division of Sports Medicine, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Hypothesis/background: In 2017, the American Orthopaedic Association advocated for the increased use of telehealth as an assessment and treatment platform, and demand has significantly increased during the coronavirus disease 2019 pandemic. Diagnostic effectiveness (also called overall diagnostic accuracy) and reliability of a telehealth clinical examination vs. a traditional shoulder clinical examination (SCE) has not been established. Our objective is to compare the diagnostic effectiveness of a telehealth shoulder examination against an SCE for rotator cuff tear (RCT), using magnetic resonance imaging (MRI) as a reference standard; secondary objectives included assessing agreement between test platforms and validity of individualized tests. We hypothesize that tests provided in a telehealth platform would not have inferior diagnostic effectiveness to an SCE.

Methods: The study is a case-based, case-control design. Two clinicians selected movement, strength, and special tests for the SCE that are associated with the diagnosis of RCT and identified similar tests to replicate for a simulated telehealth-based examination (STE). Consecutive patients with no prior shoulder surgery or advanced imaging underwent both the SCE and STE in the same visit using 2 separate assessors. We randomized the order of the SCE or STE. A blinded reader assessed an MRI, to be used as a reference standard. We calculated diagnostic effectiveness, which provides values from 0% to 100% as well as agreement statistics (Kappa) between tests by an assessment platform, and sensitivity, specificity, and likelihood ratios for individual tests in both SCE and STE. We compared the diagnostic effectiveness (overall) of the SCE and STE with a Mann-Whitney U test.

Results: We included 62 consecutive patients with shoulder pain, aged 40 or older; 50 (81%) received an MRI as a reference standard. The diagnostic effectiveness of stand-alone tests was poor regardless of the group, with the exception of a few tests with high specificity. None had greater than 70% accuracy. There was no significant difference between the overall diagnostic effectiveness of the STE and SCE (P = .98). Overall agreement between the STE tests and the SCE tests ranged from poor to moderate (Kappa, 0.07-0.87).

Conclusion: This study identified initial feasibility and noninferiority of the physician-guided, patient-performed STE when compared with an SCE in the detection of RCTs. Although these results are promising, larger studies are needed for further validation of an STE assessment platform.
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http://dx.doi.org/10.1016/j.jse.2020.08.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455801PMC
May 2021

Risk of suprascapular nerve injury during glenoid baseplate fixation for reverse total shoulder arthroplasty: a cadaveric study.

J Shoulder Elbow Surg 2021 Mar 21;30(3):532-537. Epub 2020 Jul 21.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Reverse total shoulder arthroplasty (rTSA) is an effective treatment for patients with advanced rotator cuff arthropathy. During implantation of the glenoid baseplate, screws are inserted through the glenoid face into the scapular body to achieve adequate fixation. Placement of peripheral baseplate screws in the superior and posterior glenoid may increase the risk of injury to the suprascapular nerve (SSN). The purpose of this cadaveric study was to evaluate the risk of SSN injury with placement of baseplate screws in the superior and posterior direction.

Methods: Twelve cadaveric shoulders were implanted with glenoid baseplates. A bicortical 44-mm screw was placed in both the superior and posterior glenoid baseplate screw holes. Following implantation, the SSN was dissected and visualized through a posterior shoulder approach. The distance from the tip of the screws to the SSN and the distance from the screw's scapular exiting hole to the SSN was recorded. Average distances were calculated for each measurement.

Results: The superior screw contacted the SSN in 8 of the 12 specimens (66%). For the superior screw, the average distance from the exiting point in the scapula to the SSN was 9.2 ± 6.3 mm, with the shortest distance being 3.9 mm. The posterior screw contacted the SSN in 6 of 12 specimens (50%). For the posterior screw, the average distance from the exiting point to the SSN was 8.9 ± 3.8 mm, with the shortest distance to the nerve being 2.2 mm.

Conclusion: Placement of the superior and posterior screws in the glenoid baseplate during rTSA risks injury to the SSN. The safe zone for superior- and posterior-directed baseplate screw is <2 mm from its exiting point on the scapula. Therefore, precise measurements of screw lengths in this area is important in avoiding injury to the SSN.
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http://dx.doi.org/10.1016/j.jse.2020.07.008DOI Listing
March 2021

Anterolateral Complex Reconstruction Augmentation of Anterior Cruciate Ligament Reconstruction: Biomechanics, Indications, Techniques, and Clinical Outcomes.

JBJS Rev 2019 11;7(11):e5

Duke Sport Science Institute, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina.

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http://dx.doi.org/10.2106/JBJS.RVW.19.00011DOI Listing
November 2019

Biceps tenotomy has earlier pain relief compared to biceps tenodesis: a randomized prospective study.

Knee Surg Sports Traumatol Arthrosc 2019 Dec 5;27(12):4032-4037. Epub 2019 Sep 5.

Department of Orthopaedic Surgery, Durham Veterans Affairs Medical Center, Duke University Medical Center, Box 3000, Durham, NC, 27710, UK.

Purpose:  Surgical management for long head of the biceps (LHB) tendinopathy with either biceps tenotomy or tenodesis is a reliable, but debated treatment option. The aim of this prospective, randomized, single-blinded study is to evaluate differences in pain relief and subjective outcomes between biceps tenotomy versus tenodesis for LHB tendinopathy.

Methods:  Subjects were randomized and blinded to biceps tenotomy versus arthroscopic tenodesis intra-operatively. Outcomes evaluated included subjective patient outcome scores, pain, and cosmetic deformity. Subjective outcomes scores and pain were analyzed using a two-way ANOVA, controlling for concomitant rotator cuff repair. Binary outcomes were compared using Chi-square tests.

Results:  Thirty-four subjects (31 male, 3 female) with a median age of 56 (range 30-77) were enrolled. Twenty subjects were randomized to tenotomy and 14 to tenodesis. Fifty-six percent had concomitant rotator cuff repairs. The mean VAS pain score at 3 months was lower with tenotomy versus tenodesis. 2-year follow-up demonstrated no statistically significant differences for VAS, ASES, or SANE. 15/20 (75%) subjects with biceps tenotomy reported no pain medication use at the 2-week postoperative visit versus 5/14 (33%) for biceps tenodesis. Popeye deformity was found in 5/20 (25%) of tenotomy subjects versus 1/14 (7%) in tenodesis subjects.

Conclusion: Outcomes appear similar between biceps tenotomy versus tenodesis; however, the tenotomy group demonstrated greater incidence of cosmetic deformity but an earlier improvement in postoperative pain.

Level Of Evidence: Treatment Studies, Level II.
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http://dx.doi.org/10.1007/s00167-019-05682-1DOI Listing
December 2019

Correlation of Single Assessment Numerical Evaluation Score for Sport and Activities of Daily Living to Modified Harris Hip Score and Hip Outcome Score in Patients Undergoing Arthroscopic Hip Surgery.

Am J Sports Med 2019 09 26;47(11):2646-2650. Epub 2019 Jul 26.

Duke Sport Science Institute, Department of Orthopaedics, Duke University Medical Center, Wake Forest, North Carolina, USA.

Background: The Single Assessment Numerical Evaluation (SANE) is a single-question outcome score that has been shown to be a reliable measure of outcomes for shoulder and knee injuries but has not been compared with other validated outcome scores in hip pathology managed arthroscopically.

Purpose: To correlate SANE Activities of Daily Living (ADL) and Sport subscales with the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS) ADL and Sport subscales before and after arthroscopic hip surgery.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: A retrospective review of a prospectively filled database of patients undergoing arthroscopic hip surgery by a single surgeon was conducted. Inclusion criteria included patients scheduled for arthroscopic hip surgery for femoroacetabular impingement, labral tear, or gluteus medius tear. Exclusion criteria included previous surgery to the hip. Outcome scores, including the mHHS, HOS ADL and Sport, and SANE ADL and Sport, were measured preoperatively and postoperatively at 3 months, 1 year, and then annually. Pearson correlation coefficients between preoperative SANE ADL and Sport and the mHHS, HOS ADL, and HOS Sport were calculated. Pearson correlation coefficients between postoperative SANE ADL and Sport and the mHHS, HOS ADL, and HOS Sport were also calculated.

Results: Eighty-five patients (mean age, 37.9 years; range, 14-66 years; 57 females, 28 males) underwent arthroscopic hip surgery for assorted pathology. Mean follow-up was 8 months (range, 3-64 months). Based on the Pearson correlation coefficient, preoperative SANE ADL and Sport had a moderate correlation with the mHHS ( = 0.66; 95% CI, 0.47-0.79; < .0001; = 0.54; 95% CI, 0.31-0.71; < .0001, respectively). Preoperative SANE ADL and Sport had a moderate correlation with HOS ADL ( = 0.60; 95% CI, 0.39-0.75; < .0001) and HOS Sport ( = 0.65; 95% CI, 0.45-0.79; < .0001). Postoperative SANE ADL and Sport had a strong correlation with the mHHS ( = 0.69; 95% CI, 0.50-0.82; < .0001; = 0.78; 95% CI, 0.61-0.88; < .0001). Postoperative SANE ADL and Sport had a strong correlation with HOS ADL ( = 0.79; 95% CI, 0.65-0.88; < .0001) and HOS Sport ( = 0.88; 95% CI, 0.78-0.94; < .0001).

Conclusion: This study showed a significant correlation between SANE and mHHS in patients undergoing arthroscopic hip surgery both pre- and postoperatively. SANE ADL and Sport had a strong correlation with HOS ADL and Sport preoperatively and short-term postoperatively. SANE scores are more highly correlated with traditional subjective outcome measures during the short-term postoperative period than they are preoperatively. The SANE score provides an efficient method of assessing outcomes after hip arthroscopy.
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http://dx.doi.org/10.1177/0363546519863411DOI Listing
September 2019

Clinical and Radiographic Outcomes of the Simpliciti Canal-Sparing Shoulder Arthroplasty System: A Prospective Two-Year Multicenter Study.

J Bone Joint Surg Am 2016 Apr;98(7):552-60

Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, Illinois.

Background: Stemmed humeral components have been used since the 1950s; canal-sparing (also known as stemless) humeral components became commercially available in Europe in 2004. The Simpliciti total shoulder system (Wright Medical, formerly Tornier) is a press-fit, porous-coated, canal-sparing humeral implant that relies on metaphyseal fixation only. This prospective, single-arm, multicenter study was performed to evaluate the two-year clinical and radiographic results of the Simpliciti prosthesis in the U.S.

Methods: One hundred and fifty-seven patients with glenohumeral arthritis were enrolled at fourteen U.S. sites between July 2011 and November 2012 in a U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE)-approved protocol. Their range of motion, strength, pain level, Constant score, Simple Shoulder Test (SST) score, and American Shoulder and Elbow Surgeons (ASES) score were compared between the preoperative and two-year postoperative evaluations. Statistical analyses were performed with the Student t test with 95% confidence intervals. Radiographic evaluation was performed at two weeks and one and two years postoperatively.

Results: One hundred and forty-nine of the 157 patients were followed for a minimum of two years. The mean age and sex-adjusted Constant, SST, and ASES scores improved from 56% preoperatively to 104% at two years (p < 0.0001), from 4 points preoperatively to 11 points at two years (p < 0.0001), and from 38 points preoperatively to 92 points at two years (p < 0.0001), respectively. The mean forward elevation improved from 103° ± 27° to 147° ± 24° (p < 0.0001) and the mean external rotation, from 31° ± 20° to 56° ± 15° (p < 0.0001). The mean strength in elevation, as recorded with a dynamometer, improved from 12.5 to 15.7 lb (5.7 to 7.1 kg) (p < 0.0001), and the mean pain level, as measured with a visual analog scale, decreased from 5.9 to 0.5 (p < 0.0001). There were three postoperative complications that resulted in revision surgery: infection, glenoid component loosening, and failure of a subscapularis repair. There was no evidence of migration, subsidence, osteolysis, or loosening of the humeral components or surviving glenoid components.

Conclusions: The study demonstrated good results at a minimum of two years following use of the Simpliciti canal-sparing humeral component. Clinical results including the range of motion and the Constant, SST, and ASES scores improved significantly, and radiographic analysis showed no signs of loosening, osteolysis, or subsidence of the humeral components or surviving glenoid components.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.15.00181DOI Listing
April 2016

Cost-effectiveness analysis of the diagnosis of meniscus tears.

Am J Sports Med 2015 Jan 1;43(1):128-37. Epub 2014 Dec 1.

Department of Medicine and the Center for Applied Genomics & Precision Medicine, Duke University Medical Center, Durham, North Carolina, USA.

Background: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy.

Purpose: To identify the most efficient strategy for the diagnosis of meniscus tears.

Study Design: Economic and decision analysis; Level of evidence, 1.

Methods: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER).

Results: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively.

Conclusion: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test.

Clinical Relevance: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.
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http://dx.doi.org/10.1177/0363546514557937DOI Listing
January 2015

Aberrant origin of the long head of the biceps.

J Shoulder Elbow Surg 2012 Nov;21(11):e21

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http://dx.doi.org/10.1016/j.jse.2012.08.007DOI Listing
November 2012

Aberrant origin of the long head of the biceps: a case series.

J Shoulder Elbow Surg 2012 Mar 11;21(3):356-60. Epub 2011 Aug 11.

Division of Orthopaedic Surgery, Bassett Healthcare Network, Cooperstown, NY 13326, USA.

Background: Variants of the origin of the long head of the biceps have been described intraoperatively. It is unclear whether these variants contribute to shoulder pathology. Our purpose was to describe an anatomic variation of the origin of the long head of the biceps and associated clinical presentations of 2 subjects and to review existing reports of other variants.

Methods: We present the history and physical examination, imaging, and arthroscopic findings of 2 cases of an abnormal variant of the origin of the long head of the biceps.

Results: In 2 subjects, the long head of the biceps was noted to have a Y-shaped origin with 1 limb coming from the rotator cable and the other limb taking origin medial to the superior glenoid tubercle. A 42-year-old male weightlifter presented with distal clavicle osteolysis confirmed by diagnostic injection and had resolution of symptoms after a distal clavicle excision. A 38-year-old female retired military officer presented with subcoracoid impingement confirmed by magnetic resonance imaging findings and a diagnostic injection and did well after subcoracoid decompression. In neither case did the biceps tendon appear diseased or related to shoulder pathology.

Conclusions: In rare cases, the long head of the biceps takes origin from the rotator cable and has a second origin medial to the supraglenoid tubercle. This variant does not appear to contribute to shoulder pathology because standard treatment of concomitant diagnoses resulted in resolution of symptoms.
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http://dx.doi.org/10.1016/j.jse.2011.05.006DOI Listing
March 2012
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