United States

Background: Scoliosis is a common spinal malformation, which is typically diagnosed and assessed for severity by measuring the Cobb angle on a plain radiograph. Although manual methods are still considered the gold standard, recent studies have shown that PACS (picture archiving and communication systems methods) have comparable intraobserver and interobserver reliability levels for experienced clinicians. However, there is limited data for these reliability measures in less experienced medical personnel, especially with digital methods like PACS.

Methods: 10 radiographic images of scoliosis patients were obtained via a retrospective chart review. After a brief training exercise, Cobb angle measurements were performed twice on each radiograph, separated by one week, using the PACS method. Subject groups ranged in their level of prior training and experience with Cobb angle measurements from inexperienced medical students, to more experienced resident physicians, and highly experienced orthopedic surgeons and radiologists. Data was compared for interrater reliability levels within groups and between groups, and for individual intra-rater reliability levels. Intra-class correlation coefficient (ICC) between averaged measured were calculated and a Cronbach’s α obtained. An α of ≥ 0.9 is considered excellent agreement, 0.9 &gt; α ≥ 0.8 is good, 0.8 &gt; α ≥ 0.7 is acceptable, 0.7 &gt; α ≥ 0.6 is questionable and α &lt; 0.6 is poor or unacceptable reliability. 

Results: Resident physicians, orthopedic surgeons, and radiologist subject groups had significant levels of between-group and within-group inter-rater reliability as well as individual intra-rater reliability levels (α ≥ 0.9, p&lt;0.001). Inexperienced medical student raters had poor within-group interrater reliability (α = -0.176). One medical student had a significant level of individual intra-rater reliability (α &gt; 0.9, p&lt;0.001) while the other had poor intra-rater reliability (α &lt; 0.6, p=0.035). Between-group inter-rater reliability for medical students and more experienced professionals was poor (α &lt; 0.6).

Conclusions: While PACS has been shown to be a reliable method for measuring Cobb angle and an acceptable substitute for conventional manual techniques, it is not a reliable method in less experienced trainees such as medical students. 


AMA Research Challenge 2022

Reliability of Cobb angle measurement using PACS in less-experienced medical personnel

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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Background: Scoliosis is a common spinal malformation, which is typically diagnosed and assessed for severity by measuring the Cobb angle on a plain radiograph. Although manual methods are still considered the gold standard, recent studies have shown that PACS (picture archiving and communication systems methods) have comparable intraobserver and interobserver reliability levels for experienced clinicians. However, there is limited data for these reliability measures in less experienced medical personnel, especially with digital methods like PACS.

Methods: 10 radiographic images of scoliosis patients were obtained via a retrospective chart review. After a brief training exercise, Cobb angle measurements were performed twice on each radiograph, separated by one week, using the PACS method. Subject groups ranged in their level of prior training and experience with Cobb angle measurements from inexperienced medical students, to more experienced resident physicians, and highly experienced orthopedic surgeons and radiologists. Data was compared for interrater reliability levels within groups and between groups, and for individual intra-rater reliability levels. Intra-class correlation coefficient (ICC) between averaged measured were calculated and a Cronbach’s α obtained. An α of ≥ 0.9 is considered excellent agreement, 0.9 > α ≥ 0.8 is good, 0.8 > α ≥ 0.7 is acceptable, 0.7 > α ≥ 0.6 is questionable and α < 0.6 is poor or unacceptable reliability. 

Results: Resident physicians, orthopedic surgeons, and radiologist subject groups had significant levels of between-group and within-group inter-rater reliability as well as individual intra-rater reliability levels (α ≥ 0.9, p<0.001). Inexperienced medical student raters had poor within-group interrater reliability (α = -0.176). One medical student had a significant level of individual intra-rater reliability (α > 0.9, p<0.001) while the other had poor intra-rater reliability (α < 0.6, p=0.035). Between-group inter-rater reliability for medical students and more experienced professionals was poor (α < 0.6).

Conclusions: While PACS has been shown to be a reliable method for measuring Cobb angle and an acceptable substitute for conventional manual techniques, it is not a reliable method in less experienced trainees such as medical students.

poster

Abstract Title: 
Reverse Total Shoulder Arthroplasty: The Impact of Implant Design on Postoperative Internal Rotation

Background
Reverse total shoulder arthroplasty (rTSA) is a ubiquitous surgical procedure indicated for numerous glenohumeral pathologies. Repeated evidence demonstrates its efficacy in improving shoulder function and reducing pain; however, improvements in rotational motion have been inconsistent. Attention has recently shifted toward internal rotation (IR) as an important component of activities of daily living (ADL). Subsequently, IR has been strongly associated with post-operative patient satisfaction. To date, there has been little discussion regarding implant design on IR. As the community shifts toward more lateralized center-of-rotation and varus humeral implants, it is unclear how this will impact rotational motion.

Methods
A systematic review was performed following PRISMA guidelines. Search strategies were implemented in PubMed with the keywords (internal rotation) AND (reverse) AND (shoulder). Inclusion criteria included a minimum 12-month follow-up, reporting of IR, and implant description. Exclusion criteria included rTSA solely for proximal humerus fractures, oncologic reconstruction, or severe glenoid deformity, revision rTSA, and procedures including latissimus dorsi or tendon transfers. After review, 56 studies from 332 unique citations were selected.

Results
Analysis was performed on 56 studies consisting of 7788 shoulders treated with rTSA at a mean follow-up of 42.4 months. IR was reported for 7288 shoulders (94%). Measurement systems were highly heterogeneous necessitating conversion to a common metric. This permitted comparative analysis of 46 studies encompassing 6123 shoulders (79%).

Varus (135°) humeral implant neck shaft angles (NSA) were associated with the greatest post-operative IR, though intermediate (145-147°) and valgus (150-155°) NSA produced comparable results. Varus and intermediate NSA outperformed valgus NSA in terms of mean change in IR.

Accounting for humeral NSA, lateralized glenospheres resulted in greater post-operative IR. When classifying implant systems with the Werthel global offset system, highly lateralized and very highly lateralized systems produced greater post-operative IR than medialized systems.

Conclusion
The results of this systematic review indicate that lateralization of the center-of-rotation and varus humeral NSA optimize IR. A classic Grammont-style rTSA, a medialized center-of-rotation with a valgus NSA, was associated with predictably poor IR. This review suggests trends toward lateralized center of rotation and varus NSA will result in improved IR.


Reverse Total Shoulder Arthroplasty: The Impact of Implant Design on Postoperative Internal Rotation

Risk Factors and Characteristics of Recalcitrant Osteomyelitis Following Appropriate Surgical and Antibiotic Treatment

Introduction: The purpose of this study was to compare osteoarthritis (OA) diagnosis prevalence between isolated anterior cruciate ligament (ACL) reconstruction and ACL reconstruction with meniscus involvement (meniscus repair (MR), partial meniscectomy (APM), both isolated and combined). We hypothesized that meniscus injury in combination with ACL injury would have increased OA prevalence. 
Methods: The PearlDiver Mariner database was used in this study which contains insurance claims information on more than 91 million orthopaedic patients. Five cohorts were identified for this study using Current Procedural Terminology (CPT) codes and included those between the ages of 16 and 60 that underwent isolated ACL reconstruction, isolated MR, ACL+MR, isolated APM, or ACL+APM repair. Groups were matched by patient age, sex, and presence of diagnosis codes for obesity and morbid obesity with each group consisting of 10,125 patients (4685 females and 5440 males). OA prevalence and odds ratio were compared against isolated ACL reconstruction. 
Results: A significantly greater proportion of APM and ACL+APM patients were diagnosed with knee OA within five years of surgery when compared to isolated ACL patients (APM= 735/10,125 (7.3%) and ACL+APM= 459 (4.5%) vs ACL= 338 (3.3%), p=<0.0001 for both comparisons). The odds of knee OA were also greater in APM and ACL+APM patients when compared to isolated ACL patients (Odds Ratio: APM= 2.27 and ACL+APM= 1.38). Patients undergoing isolated MR also demonstrated a slight, yet still statistically significant, increase in OA prevalence and odds within five years of surgery (MR= 396 (3.9%), Odds Ratio= 1.18, p=0.03). Patients undergoing ACL+MR showed a decrease in prevalence of OA when compared to isolated ACL reconstruction (ACL+MR= 254 (2.5%), odds ratio= 0.75, p=0.0005).
Conclusions: Our results support the hypothesis that meniscus injury at arthroscopy significantly increases the risk of developing diagnosed OA within five years. APM, whether isolated or combined with ACL reconstruction, demonstrated the greatest incidence of OA within 5 years when compared to matched groups of patients that underwent ACL reconstruction and/or meniscus repair. These “big data” results confirm previous reports from prospective ACL cohorts, and further support efforts to repair the menisci whenever possible. Interestingly, the lowest incidence of subsequent OA diagnosis was in the group that underwent combined ACL reconstruction and meniscus repair. Future research is needed to better understand the biological and biomechanical mechanisms that contribute to the potentially protective effect of combined ACL reconstruction and meniscus repair.

Save the Meniscus! Incidence of Osteoarthritis Diagnosis Greatest Following Partial Meniscectomy, Either Isolated or in Combination with ACL Reconstruction

Introduction: Despite the prevalence of osteoarthritis in patients with multiple sclerosis (MS) being equivalent to that of the general population, very little research exists on outcomes and complications following shoulder arthroplasty in patients with this condition. The purpose of the current study was to utilize a national database to determine the effect of MS on implant related complications following anatomic and reverse shoulder arthroplasty procedures and evaluate for any differences in complications between the two prosthesis types. 

Methods: Patients with MS who underwent anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) were identified in a national insurance database using the appropriate ICD-9 and ICD-10 diagnostic codes. Patients who underwent TSA, RSA, and RSA for fracture with a diagnosis of MS were identified and compared to non-MS cohorts in a 5:1 manner. Each cohort was then assessed for revision surgery, periprosthetic joint infection, and prosthetic dislocation and compared.

Results: Patients with MS undergoing RSA for fracture experienced increased rates of periprosthetic joint infection compared to those undergoing RSA for fracture without MS (OR 3.6, CI 1.47-8.91, p = 0.035). There were no other significant differences when comparing complications between patients with MS undergoing shoulder arthroplasty procedures compared to controls without the disorder, or any significant differences when comparing complications between patients with MS undergoing TSA and RSA (p > 0.05).

Conclusions: Patients undergoing RSA for fracture with MS appear to be at increased risk for postoperative periprosthetic joint infection compared to patients without MS, and should be counseled accordingly. However, MS does not appear to confer a statistically significant increased risk for the remainder of the studied complications following TSA, RSA, and RSA for fracture. The current study suggests that surgeons should not alter their treatment strategies or implant selection for patients undergoing shoulder arthroplasty based on a diagnosis of MS.

Shoulder Arthroplasty in Patients with Multiple Sclerosis - Complications Stratified by Arthroplasty Type

Obesity, defined as a body mass index (BMI) ≥ 30, is associated with musculoskeletal injuries. Past literature assumed low BMI was a risk factor for fractures, and high BMI was protective against fractures. However, present studies suggest that the relationship between obesity and the risk of fracture is site-specific. To our knowledge, no study has considered the impact of obesity on tibial plateau fracture, the proximal end of the tibia. Therefore, this study aims to investigate if obese patients are at higher risk of developing open proximal tibia fractures when compared with non-obese patients with a similar mechanism of injury.
A retrospective study was performed at a level one trauma hospital, and we identified patients with proximal tibia fracture from January 1, 2015, to December 31, 2019. We reviewed electronic records for demographic variables, fracture type (open or closed) and categorized patients into obese for BMI ≥30 kg/m2 or non-obese for BMI 18.5-24.9 kg/m2. We categorized the mechanism of injury into four injury patterns: assault, fall, motor vehicle accident (MVC), and motorcycle accident. For statistical analysis, we performed t-tests and p-value of 0.05 to be statistically significant.
Sixty patients with proximal tibia fractures were included, and seven percent sustained open proximal tibia fractures. The mean BMI was 32 kg/m2. Overall, 63% of the patients had an obese BMI, and 37% had a non-obese BMI. One hundred percent of patients with open proximal tibia fracture had BMI ≥30 kg/m2; however, the type of fracture (open vs. closed) was not statistically significant (p = 0.286) between the obese and non-obese groups. We also observed that all the patients with open proximal tibia fractures were involved in MVC. However, we observed no statistically significant relationship (p = 0.357) when we looked at the effect of being obese on the likelihood of having an open fracture for those whose mechanism of injury is MVC.

Research on obesity and lower extremity fractures has provided varying and complicating results. Our study demonstrated that obese individuals do not have an increased risk of developing open proximal tibia fractures than non-obese individuals following the same mechanism of injury.


The Association between Open Proximal Tibia Fractures and Obesity

The Association Between Preoperative Diabetes Status and Adverse Events Following Primary Anterior Cruciate Ligament Reconstruction

Introduction: 
Anatomic total shoulder arthroplasty (ATSA) has proven to be a successful treatment for glenohumeral osteoarthritis (GHOA). Nonetheless, it is uncertain if there is a correlation between pre-operative rotator cuff muscle atrophy on post clinical outcomes in patients who get an ATSA. The purpose of this study is to evaluate if there is a correlation between pre-operative rotator cuff muscle volume and clinical outcomes following ATSA for GHOA. 

Methods:
In this study, 198 shoulders underwent ATSA for GHOA with a minimum of 2 years follow up identified by a maintained prospective registry. Each rotator cuff muscle was assessed and measured on a standardized preoperative magnetic resonance image (MRI), using OsiriX image analysis, to generate an area of total muscle volume. The pre and postoperative patient reported clinical outcomes are the American Shoulder and Elbow standardized shoulder assessment (ASES), Single Assessment Numerical Evaluation (SANE), range of motion (ROM), and pain level. The above outcomes were assessed for correlations with preoperative rotator cuff muscle volume.

Results: 
A total of 198 patients with a mean age of 62.0 ± 7.3 years (range: 42-78), underwent ATSA for GHOA with a minimum follow up of 2 years. MRIs were evaluated for a quantitative measurement of muscle atrophy. A univariate analysis did not show any significant findings when evaluating for supraspinatus, teres minor, and infraspinatus muscle volume in relation to clinical outcomes. There was a negative correlation in subscapularis muscle volume and its impact on postoperative internal rotation (R= -.142, P = 0.046). Furthermore, the size ratio of the posterior cuff to subscapularis muscle volume demonstrated a significant negative correlation for change in SANE scores (R= -.141, P= 0.047), external rotation (R= -0.149, P= 0.036), and internal rotation (R= -0.190, P=0.007). Nonetheless, there were no correlations between size ratio and other clinical outcomes. 

Conclusion: 
Preoperative rotator cuff muscle volume does not have an obvious correlation on clinical outcomes. However, there is a negative association with the ratio of the posterior cuff to subscapularis, consistent with prior studies that have assessed volume in patients undergoing reverse total shoulder arthroplasty. 


The Effect of Rotator Cuff Integrity on Clinical Outcomes Following Anatomic Total Shoulder Arthroplasty

Abstract Title: 
The Single Assessment Numeric Evaluation (SANE), PROMIS-UE, & QuickDASH for Elective Hand Surgeries
Background:
Validated patient-reported outcome measures provide important insight into condition-specific clinical outcomes, but they place a considerable time burden on patients, clinicians, and other staff. In response, efforts have been made to validate single-question surveys, such as the Single Assessment Numeric Evaluation (SANE) score, across orthopedic conditions, but few prospective studies have evaluated the SANE questionnaire for hand conditions specifically. Therefore, the purpose of this study was to validate the use of the SANE score in patients undergoing routine elective hand surgeries. We hypothesized that SANE scores would positively correlate with two other validated upper extremity surveys, PROMIS-UE and Quick-DASH. 
Methods:
Patients scheduled to undergo carpal tunnel release and trigger finger release surgery completed three surveys (SANE, the Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS-UE) item bank, and the shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire) preoperatively and at two postoperative time points (2-4 weeks postop and >90 days postop). Based on an a priori power calculation and values from previous studies, a minimum sample of 82 patients was needed to achieve 80% power to detect a change after treatment or intervention of the minimal clinically important difference (MCID) or greater on the QuickDASH with a 2-sided level of significance of .025.
Results:
A total of 89 patients completed all three timepoints. There were strong positive correlations between the changes in QuickDASH scores and the changes in PROMIS-UE scores between all three timepoints, which we expected since these surveys served as our controls. There was also a strong positive correlation between the changes in the SANE scores and the changes in QuickDASH scores when comparing early post-op to late post-op (Pearson coefficient 0.529187631, p-value <0.0001). All other timepoint comparisons had a moderate positive correlation between SANE and the validated surveys. 
Conclusion:
One possible explanation as to why most of our correlations were moderate rather than strong is because of the difference in scaling. SANE’s 0%-100% scale allowed for a much larger percent change than the other two surveys’ (SANE's percent change range was 0-2900%, whereas QuickDASH's was 0-115.8% and PROMIS-UE's was 0-154.2%). Future studies are recommended to determine if changing the SANE scale to 1-10 would remedy this and lead to stronger correlations. With this in mind, our data still suggest that SANE can successfully evaluate elective hand surgery outcomes in the early and late postoperative periods.

The Single Assessment Numeric Evaluation (SANE), PROMIS-UE, and QuickDASH for Elective Hand Surgeries

Abstract Title: The Use of Preoperative CRP and ESR as Predictive Markers of Prosthetic Joint Infection in Primary Total Hip and Knee Arthroplasty
Background
Total hip (THA) and total knee (TKA) arthroplasty are two of the most performed orthopedic surgeries each year in the United States. Prosthetic joint infection (PJI) remains one of the most common serious complications among all patients undergoing total joint arthroplasty (TJA). There has been a significant amount of literature on the use of c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in the field of TJA, specifically for the diagnosis of PJI. However, there is much less data focused on the use of preoperative CRP and ESR in the setting of primary TJA. The purpose of this study was to further investigate any correlation that exists between preoperative CRP/ESR and PJI in primary TJA.
Methods
All patients of one of two surgeons who underwent primary THA or TKA between 2016 and 2020 at the same institution were identified and studied via a retrospective chart review. After exclusion criteria, 806 patients were included in the final cohort for analysis. Positive CRP was set at >0.3 mg/dL and ESR as >30 mm/hr.
Results
In our current study, which is the second-largest cohort to date that looks at preoperative inflammatory markers before primary TJA, we found no statistically significant correlation between pre-operative CRP or ESR and PJI. We did find that a higher proportion of patients with PJI had elevated preoperative CRP (70.6%) vs those with normal CRP (29.4%). However, among patients with no PJI, the preoperative CRP was still found to be elevated in half of all patients (49.7%).
Conclusion
This study is unable to validate the use of preoperative CRP/ESR as a predictive measure of future risk of PJI in primary total joint arthroplasty. However, it does provide quantitative insight into the prevalence of elevated preoperative inflammatory markers in all patients prior to TJA with a considerable proportion of patients having modifiable risk factors. Since there is such a large proportion of patients with elevated inflammatory markers that do not go on to develop PJI, we do not recommend cancellation of TJA unless there is an obvious identified modifiable risk factor that puts them at increased risk of PJI.

The Use of Preoperative Crp and Esr as Predictive Markers of Prosthetic Joint Infection in Primary Total Hip and Knee Arthroplasty

Background
Opioid overdose has been on the constant rise since the beginning of the opioid epidemic. Orthopedic surgery has the 3rd highest average number of opioid prescriptions per prescriber. Efforts have been made nationally to decrease opioid prescribing and opioid use and abuse. Studies have shown patients with mental health disorders are more likely to be prescribed medications, such as opioids, for chronic pain management. This study aims to investigate the trends in prescription rates of analgesic medications for primary total shoulder arthroplasty (TSA) patients with a history of mental illness, chronic pain, or substance use.
Methods
A retrospective trends analysis was performed using a national database. Patients who underwent primary TSA were identified using the International Classification of Disease. Patients with diagnoses of mental illness, pain syndromes, and substance use were compared to a control group without diagnoses. Patients with a history of an opioid prescription claim within 6 months before TSA were excluded. Medications prescribed—opioids, gabapentinoids (GBPs), and nonsteroidal anti-inflammatory (NSAIDs)—were identified using Uniform Systems of Classification and codes specific to the database. Annual medication claims rates within 30 days, 90 days, and 1-year after TSA were analyzed with linear regression and compound annual growth.
Results
A total of 82,692 patients with a history of mental illness, chronic pain, or substance use underwent primary TSA. Among this cohort of patients, opioid prescription claims had significantly increasing trends by 30-days after surgery, however, trends were significantly decreasing by 90-days and 1-year after surgery. Prescription claims for GBPs were significantly increasing by all timepoints after TSA surgery among this cohort. For NSAIDs, prescription claims significantly increased by 30 and 90-days post-surgically while decreasing by the 1-year mark.
Conclusion
Patients with a diagnostic history of mental health, chronic pain, or substance use have significantly fewer opioid medication prescription claims after total shoulder arthroplasty surgery than patients who do not have those diagnoses. No difference in average prescription claims was observed between groups with GBPs or NSAIDs in the 30-day or 90-day postoperative periods.





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Reverse Total Shoulder Arthroplasty: The Impact of Implant Design on Postoperative Internal Rotation

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