Brent J. Morris

Risk factors of infection after ORIF of bicondylar tibial plateau fractures.

Objectives: This study was designed to evaluate risk factors of infection after bicondylar tibial plateau fractures. We hypothesized that open fractures and smoking would be associated with deep infection requiring reoperation. Design: We retrospectively identified all bicondylar (AO/OTA 41-C) tibial plateau fractures treated operatively over an 8-year period from 2002 to 2010. Setting: Single, high-volume, level 1 trauma center. Patients/Participants: A total of 302 patients aged 18 years and older were identified as undergoing operative fixation of bicondylar (AO/OTA 41-C) tibial plateau fractures during this time period. Intervention: Open reduction internal fixation of bicondylar (AO/OTA 41-C) tibial plateau fractures. Main Outcome Measurements: Bivariate and multivariable logistic regression analyses were used to assess the association between patient demographics and clinical characteristics and deep infection requiring reoperation. Variables that were significant at P < 0.05 in bivariate analyses were entered into a multivariable logistic regression model. Results: Forty-three (14.2%) of 302 patients developed deep infection requiring reoperation. Methicillin-resistant Staphylococcus aureus (MRSA) was cultured in 20 (46.5%) of 43 patients with deep infections. An external fixator was initially placed before definitive fixation in 81.4% of patients and definitive surgical treatment was delayed by an average of 17.5 days. Eighty-five (28.1%) patients required a reoperation after definitive fixation. Open fracture (OR, 3.44; P = 0.003), smoking (OR, 2.40; P = 0.02), compartment syndrome requiring fasciotomies (OR, 3.81; P = 0.01), and fractures requiring 2 incisions and 2 plates (OR, 3.19; P = 0.01) were all risk factors for deep infection requiring reoperation. Conclusions: In spite of a staged protocol with temporizing external fixation and delayed fixation, deep infection rate remained high. A disproportionate amount of MRSA (47%) was cultured from deep infections in this population, and MRSA prophylaxis may be considered. Smoking was the only patient modifiable predictor identified of deep infection, and patients should be informed of the increased risk of deep infection associated with their choice to continue smoking. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for periprosthetic infection after reverse shoulder arthroplasty

BACKGROUND Management of periprosthetic infection after reverse shoulder arthroplasty (RSA) remains a challenge. Whereas the infection rate after RSA has improved, more information would be helpful to identify patient risk factors for infection after RSA. The purpose of this study was to evaluate risk factors for infection after RSA. METHODS We identified 301 primary RSAs with a minimum of 1-year follow-up in a prospectively collected shoulder arthroplasty registry. We performed bivariate and multivariable logistic regression analyses to assess the association between patient demographic and clinical characteristics (age, sex, smoking, diabetes, rheumatoid arthritis, body mass index, and history of prior failed hemiarthroplasty or total shoulder arthroplasty) and periprosthetic infection after RSA. RESULTS There were 15 periprosthetic infections after RSA (5.0%). Patients with a history of RSA for failed arthroplasty (odds ratio, 5.75; 95% confidence interval, 2.01-16.43; P = .001) and patients younger than 65 years had an increased risk for development of an infection (odds ratio, 4.0; 95% confidence interval, 1.21-15.35; P = .021). History of smoking, diabetes, rheumatoid arthritis, or obesity did not contribute to an increased risk of infection after RSA. CONCLUSIONS This is the first study evaluating risk factors for infection after RSA while controlling for confounding variables with multivariable analysis. The greatest risk factors for infection after RSA were history of a prior failed arthroplasty and age younger than 65 years. Patients with these clinical characteristics should be counseled preoperatively about the increased risk for development of infection after RSA.

Characteristics of Clinical Shoulder Research Over the Last Decade: A Review of Shoulder Articles in The Journal of Bone & Joint Surgery from 2004 to 2014

BACKGROUND The purpose of this study was to determine characteristics and trends in published shoulder research over the last decade in a leading orthopaedic journal. METHODS We examined all clinical shoulder articles published in The Journal of Bone & Joint Surgery from 2004 to 2014. The number of citations, authorship, academic degrees of the authors, country and institution of origin, topic, level of evidence, positive or nonpositive outcome, and inclusion of validated patient-reported outcome measures were assessed for each article. RESULTS Shoulder articles that included an author with an advanced research degree (MD [Doctor of Medicine] with a PhD [Doctor of Philosophy] or other advanced degree) increased during the study period (p = 0.047). Level-I, II, and III studies were more likely to have an author with an advanced research degree, and Level-IV studies were more likely to have MDs only (p = 0.03). Overall, there was great variability of outcome measures, with at least thirty-nine different validated or nonvalidated outcome measures reported. CONCLUSIONS Over the last decade, there was an improvement in the level of evidence of shoulder articles published in The Journal of Bone & Joint Surgery that corresponds with recent emphasis on evidence-based medicine. A consensus is needed in shoulder research for more consistent application of validated patient-reported outcome measurement tools.

Do newer-generation bioabsorbable screws become incorporated into bone at two years after ACL reconstruction with patellar tendon graft?: A cohort study.

BACKGROUND Bioabsorbable interference screws are used frequently for graft fixation in ACL (anterior cruciate ligament) reconstruction. The resorption properties of many available screws that are marketed as bioabsorbable are not well defined. The CALAXO (Smith & Nephew Endoscopy) and MILAGRO (DePuy Synthes) bioabsorbable screws contain polymers of poly(lactic-co-glycolic acid) (PLGA) plus additives to encourage osseointegration over time. The purpose of this study was to evaluate radiographic and magnetic resonance imaging (MRI) properties and compare patient-reported outcomes at a minimum of two years of follow-up after ACL reconstruction using CALAXO or MILAGRO bioabsorbable interference screws. METHODS A cohort of patients who underwent ACL reconstruction in which the fixation used was either CALAXO or MILAGRO screws returned for repeat radiographs for evaluation of tunnel widening, repeat MRI for evaluation of graft integrity and screw breakdown, and completion of the pain and symptom items of the KOOS (Knee injury and Osteoarthritis Outcome Score) questionnaire. RESULTS At a mean of three years (range, 2.5 to 4.0 years) after surgery, thirty-one patients with sixty-two CALAXO screws and thirty-six patients with seventy-two MILAGRO screws returned for repeat evaluation. Two blinded, independent reviewers found no significant differences between the two screw types when comparing radiographs for tibial or femoral tunnel widening or MRIs for graft integrity, tibial and femoral foreign body reactions, or femoral screw degradation. Both reviewers found a significant difference between the two screw types when comparing tibial screw degradation properties (p < 0.01). All analyzed CALAXO screws were rated as partially intact or degraded; the MILAGRO screws were more likely to be rated as intact. No significant differences were noted between the two screw types when comparing the two KOOS subscales. CONCLUSIONS CALAXO screws in the tibial tunnel were more likely to be rated as degraded or partially degraded compared with MILAGRO screws at a mean of three years after implantation for ACL reconstruction. Although these newer-generation bioabsorbable screws were designed to promote osseointegration, no tunnel narrowing was noted, and in the majority of cases the remains of the screws were present at approximately three years.

Responsiveness and Internal Validity of Common Patient-Reported Outcome Measures Following Total Shoulder Arthroplasty

The Constant-Murley (Constant) score, Western Ontario Osteoarthritis of the Shoulder (WOOS) index, American Shoulder and Elbow Surgeons (ASES) score, and Single Assessment Numeric Evaluation (SANE) score are commonly used to assess patient-reported function following shoulder surgery. However, psychometric properties for these tools are mostly unknown for patients with primary glenohumeral arthritis who have undergone anatomic total shoulder arthroplasty (TSA). The purposes of this study were to (1) compare the responsiveness and internal validity between the 4 patient-reported outcomes (PROs) and (2) identify PRO score values associated with patient satisfaction after TSA. A total of 234 primary TSAs were performed for primary glenohumeral osteoarthritis with a 2-year or greater follow-up. The Constant score, WOOS index, ASES score, SANE score, and patient satisfaction were assessed preoperatively and 2 to 5 years postoperatively. Effect sizes, standardized response means, and relative efficiency were calculated to determine responsiveness, and internal validity was determined via the presence of floor and/or ceiling effects. Receiver operator characteristic (ROC) curves were constructed to identify the minimum outcome score that could correctly identify a satisfied patient. At final follow-up, 88% of patients were satisfied. The PROs had large effect sizes and standardized response means (≥0.83). The minimum score that most correctly identified a patient as satisfied was 78 for ASES score, 18 for WOOS index, 73 for Constant score, and 58 for SANE score. However, the ASES score, WOOS index, and SANE score had marked postoperative ceiling effects, whereas the Constant score was the most responsive and internally valid tool. These results suggest that the Constant score should serve as the primary PRO for patients with primary glenohumeral arthritis, whereas the WOOS index, ASES score, and SANE score could be supplementary assessments. [Orthopedics. 2017; 40(3):e513-e519.].

Comparison of satisfied and dissatisfied patients 2 to 5 years after anatomic total shoulder arthroplasty.

BACKGROUND With an increasingly large number of patients undergoing total shoulder arthroplasty (TSA) combined with increased requirements for public reporting of patient outcomes, there is a greater need to better understand the underlying factors related to patient satisfaction. The purpose of this study was to compare patient demographics, nonorthopedic comorbidities, patient-reported outcome scores, and range of motion of patients who reported being either satisfied or dissatisfied with their procedure at midterm follow-up. METHODS We identified 234 primary TSAs performed by a single surgeon for glenohumeral osteoarthritis with a minimum 2-year follow-up in a prospective shoulder arthroplasty registry. American Shoulder and Elbow Surgeons (ASES) score, patient satisfaction, and active forward flexion, abduction, and external rotation at 0° of flexion-abduction were assessed before and after TSA. RESULTS Of the 234 patients, 207 (88.5%) were satisfied with their procedure. Dissatisfied patients had significantly lower ASES scores both before and after surgery (P < .001) as well as a significantly lower preoperative to postoperative change in ASES score (P < .001). Similarly, dissatisfied patients demonstrated significantly lower changes in active forward flexion (P = .004), abduction (P = .02), and external rotation (P = .03). Patients with ASES score changes <12 points were 19 times more likely to be dissatisfied after TSA (95% confidence interval, 4.4-81.4; P = .0001). CONCLUSION Dissatisfied patients had significantly lower improvements in pain, function, and range of motion. Furthermore, a change in ASES score <12 points was associated with a 19-fold increase in the risk of being dissatisfied after TSA.

Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis

OBJECTIVE Inconclusive findings about infection risks, importantly the use of immunosuppressive medications in patients who have undergone large-joint total joint arthroplasty, challenge efforts to provide evidence-based perioperative total joint arthroplasty recommendations to improve surgical outcomes. Thus, the aim of this study was to describe risk factors for developing a post-operative infection in patients undergoing TJA of a large joint (total hip arthroplasty, total knee arthroplasty, or total shoulder arthroplasty) by identifying clinical and demographic factors, including the use of high-risk medications (i.e., prednisone and immunosuppressive medications) and diagnoses [i.e., rheumatoid arthritis (RA), osteoarthritis (OA), gout, obesity, and diabetes mellitus] that are linked to infection status, controlling for length of follow-up. METHODS A retrospective, case-control study (N = 2212) using de-identified patient health claims information from a commercially insured, U.S. dataset representing 15 million patients annually (from January 1, 2007 to December 31, 2009) was conducted. Descriptive statistics, t-test, chi-square test, Fishers exact test, and multivariate logistic regression were used. RESULTS Male gender (OR = 1.42, p < 0.001), diagnosis of RA (OR = 1.47, p = 0.031), diabetes mellitus (OR = 1.38, p = 0.001), obesity (OR = 1.66, p < 0.001) or gout (OR = 1.95, p = 0.001), and a prescription for prednisone (OR = 1.59, p < 0.001) predicted a post-operative infection following total joint arthroplasty. Persons with post-operative joint infections were significantly more likely to be prescribed allopurinol (p = 0.002) and colchicine (p = 0.006); no significant difference was found for the use of specific disease-modifying anti-rheumatic drugs and TNF-α inhibitors. CONCLUSION High-risk, post-operative joint infection groups were identified allowing for precautionary clinical measures to be taken.

Outcomes of staged bilateral reverse shoulder arthroplasties for rotator cuff tear arthropathy

BACKGROUND The purpose of this study was to evaluate outcomes in patients with rotator cuff tear arthropathy after staged bilateral reverse shoulder arthroplasties (RSAs) and to compare them with an age-, gender-, and diagnosis-matched control group with a unilateral RSA. METHODS We identified 11 patients with bilateral RSAs for rotator cuff tear arthropathy with a minimum of 2-year follow-up in a prospective shoulder arthroplasty registry. The bilateral group was matched to a control group of 19 patients with a unilateral RSA. Shoulder function scores, mobility, patient satisfaction, and activities of daily living were assessed preoperatively and at final follow-up. RESULTS There was no statistical difference between the first RSA or second RSA and the control group regarding age, gender, or follow-up. No group differences were noted preoperatively for shoulder function scores or mobility (P > .10). All groups significantly improved on all shoulder function scores (Constant score, American Shoulder and Elbow Surgeons score, Western Ontario Osteoarthritis of the Shoulder index, Single Assessment Numeric Evaluation score) and mobility at final follow-up (all P < .01). There were no significant differences in shoulder function scores or mobility between the first and second RSA in the bilateral group or between either shoulder in the bilateral group and the unilateral group (all P > .10). Patient satisfaction improved and patients were successfully able to perform many important activities of daily living after bilateral RSAs. CONCLUSIONS Patients with bilateral rotator cuff tear arthropathy can be advised that staged bilateral RSAs can be successful when indicated. Improvements in shoulder function scores, patient satisfaction, and mobility are possible for both the first RSA and the second RSA.

Reverse Shoulder Arthroplasty for Management of Postinfectious Arthropathy With Rotator Cuff Deficiency

Treatment of patients with rotator cuff deficiency and arthritis in the setting of a prior glenohumeral infection (postinfectious arthropathy) is complex, with little evidence to guide treatment. The current authors present their approach to management of these patients and clinical outcomes after reverse shoulder arthroplasty (RSA). All primary RSAs performed for postinfectious arthropathy and rotator cuff deficiency with native glenohumeral joints were identified in a prospective shoulder arthroplasty registry. Eight patients with a minimum of 2-year follow-up were included in the analysis. Clinical outcomes, including the Constant score, the American Shoulder and Elbow Surgeons (ASES) score, the Western Ontario Osteoarthritis Shoulder (WOOS) index, the Single Assessment Numeric Evaluation (SANE) score, and range of motion measurements, were assessed preoperatively and at final follow-up. At an average follow-up of 4.4 years, no patient had a clinically detectable recurrence of infection. Significant improvements were noted in all outcome scores from preoperative evaluation to final follow-up after RSA, including Constant score (P=.003), ASES score (P<.001), WOOS index (P=.002), SANE score (P=.025), forward flexion (P<.001), abduction (P<.001), and external rotation (P=.020). Seven of 8 patients reported they were satisfied or very satisfied at final follow-up. Reverse shoulder arthroplasty can be performed in patients without significant medical comorbidities in the setting of postinfectious arthropathy and rotator cuff deficiency with a low risk of recurrence of infection. Significant clinical improvements were noted at short-term follow-up.

Obesity Increases Early Complications After High-Energy Pelvic and Acetabular Fractures.

Elevated body mass index has been identified as a potential risk factor for complications in operatively treated pelvic trauma. Although obesity is an independent risk factor for morbidity and mortality following high-energy blunt force trauma, there is little information on the immediate complications following isolated pelvic and acetabular fractures in obese patients with trauma. The authors hypothesized that obesity (body mass index ≥30 kg/m(2)) is a risk factor for complications in both operative and nonoperative pelvic and acetabular fractures. The authors conducted a 5-year retrospective data collection of all patients with isolated pelvic and acetabular fractures presenting to a Level I trauma center, excluding pediatric (age <18 years) patients, those with ballistic injuries, and those with concomitant long bone fractures or an Abbreviated Injury Scale score of greater than 2 in any other body region. Complications during the immediate hospitalization period were identified by the institutions Trauma Registry of the American College of Surgeons database, including wound infection, dehiscence, deep venous thrombosis, pulmonary embolus, pneumonia, and development of decubitus ulcers. Mean body mass index was 27.4 ± 6.8 kg/m(2), with 68 (27.0%) obese patients. Mean body mass index of patients with complications was significantly higher (31.9 ± 9.5 vs 27.0 ± 6.5 kg/m(2); P=.001). Logistic regression showed that obesity was a significant risk factor for complications (odds ratio, 2.87; 95% confidence interval, 1.02-8.04), after adjusting for age (odds ratio, 1.03; 95% confidence interval, 1.01-1.06) and Injury Severity Score (odds ratio, 1.20; 95% confidence interval, 1.10-1.32). Obesity is associated with increasing complications following operative fixation of pelvic and acetabular fractures. However, it is important to recognize that even nonoperative management of pelvic and acetabular fractures in obese patients can have early complications. This study showed a significant obesity-related risk of complications after trauma in both operative and nonoperative pelvic injuries.