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Although there is increased utilization of stemless humeral implants in anatomic total shoulder arthroplasty (TSA), there are inadequate objective metrics to evaluate bone quality sufficient for fixation. Our goals are to: (1) compare patient characteristics in patients who had plans for stemless TSA but received stemmed TSA due to intraoperative assessments and (2) propose threshold values of bone density, using the deltoid tuberosity index (DTI) and proximal humerus Hounsfield units (HU), on preoperative X-ray and computed tomography (CT) to allow for preoperative determination of adequate bone stock for stemless TSA.This is an observational study conducted at an academic institution from 2019 to 2021, including consecutive primary TSAs templated to undergo stemless TSA based on 3-dimensional CT preoperative plans. Final implant selection was determined by intraoperative assessment of bone quality. Preoperative X-ray and CT images were assessed to obtain DTI and proximal humeral bone density in HU, respectively. A receiver operating characteristic curve was used to analyze the potential of preoperative X-ray and CT to classify patients as candidates for stemless TSA.A total of 61 planned stemless TSAs were included, with 56 (91.8%) undergoing stemless TSA and 5 (8.2%) undergoing stemmed TSA after intraoperative assessment determined that the bone quality was inadequate for stemless fixation. There were no significant differences between the 2 groups in terms of gender (P = .640), body mass index (P = .296), and race (P = .580). The stem cohort was significantly older (mean age 69 ± 12 years vs. 59 ± 10 years, P = .029), had significantly lower DTI (1.45 ± 0.13 vs. 1.68 ± 0.18, P = .007), and had significantly less proximal humeral HU (-1.4 ± 17.7 vs. 78.8 ± 52.4, P = .001). The receiver operating characteristic curve for DTI had an area under the curve (AUC) of 0.86, and bone density in HU had an AUC of 0.98 in its ability to distinguish patients who underwent stemless TSA vs. short-stem TSA. A threshold cutoff of 1.41 for DTI resulted in a sensitivity of 98% and a specificity of 60%, and a cutoff value of 14.4 HU resulted in a sensitivity of 95% and a specificity of 100%.Older age, lower DTI, and less proximal humeral bone density in HU were associated with the requirement to switch from stemless to short-stem humeral fixation in primary TSA. Preoperative DTI had good ability (AUC of 0.86) and preoperative HU had excellent ability (AUC of 0.98) to categorize patients as appropriate for stemless TSA. This can help surgeons adequately plan humeral fixation using standard preoperative imaging data.

Background Escherichia Coli (E coli) is a gram-negative rod that can cause devastating periprosthetic joint infections (PJIs) in patients with total hip and knee replacements (THA/TKA). Minimal literature exists on outcomes of E coli PJIs. Methods Retrospective review of our institution’s electronic medical record from 2009-2020 identified 21 patients that met MusculoSkeletal Infection Society criteria for E coli hip or knee PJI. Primary outcome was 1-year infection clearance - eradication of infection off antibiotics with no further surgeries for 1 year after completion of standard postoperative antibiotics. Minimum followup was 1 year. Results We analyzed 21 patients (mean age 66.6 yrs, 47.6% male, 23.8% nonWhite, 38.1% knee PJIs). There were 11 acute, 8 acute hematogenous (AH), and 2 chronic PJIs. Several patients had recent gastrointestinal/urinary tract surgery (14.3%), recurrent urinary tract infections (9.5%), or >1 E coli urine culture Conclusion E coli PJI 1-year infection clearance is poor, with DAIR being the most common yet least effective surgical treatment. Most E coli PJIs occurred postoperatively as opposed to hematogenously, as is sometimes assumed. This serves as a foundation for future studies evaluating E coli treatment outcomes. Disclosures William A. Jiranek, MD, Biomech Holdings LLC: Stocks/Bonds|DePuy, A Johnson & Johnson Company: IP royalties Thorsten M. Seyler, MD, PhD, Heraeus: Paid consultant|Pattern Health: IP royalties|Restor3d: IP royalties|Smith & Nephew: Paid consultant|Total Joint Orthopedics: Paid consultant|Zimmer: research.

Girdlestone resection arthroplasty is a salvage procedure for hip periprosthetic joint infection (PJI) that controls infection and reduces chronic pain, but may result in limited post-operative joint function. The aim of this study was to assess physical function and mental health after Girdlestone.This was a multicenter, prospective study evaluating patients with Girdlestone. The Prosthesis Evaluation Questionnaire (PEQ) and PROMIS Global Physical Health and Mental Health surveys were administered post-operatively via telephone. The PEQ consists of four scales (i.e., ambulation, frustration, perceived response, social burden) with scores ranging from 0 to 10. The PROMIS measures generated T scores (mean: 50, Standard Deviation (SD): 10) that enable comparison to the general population.Thirty-five patients completed all surveys. The average time from procedure to survey completion was 6 years (range, 1 to 20). The median scores for the ambulation, frustration, perceived response, and social burden scales of the PEQ were 0.0 [IQR: 0-4.1], 6.0 [3.0-9.3], 9.0 [7.2-10.0], and 7.5 [4.3-9.5]. The median raw scores of the PROMIS Global Physical Health and Mental Health were 11.91 [IQR: 9-14] and 14.0 [10.0-16.0]. These corresponded to average T-scores of 39.7 (Standard Error (SE): 4.3) for physical health and 46.1 (SE: 3.8) for mental health, which were 10.3 points and 3.9 points below the average score in the United States general population, respectively.Girdlestone can have a substantial negative impact on physical function; however, mental health and social interaction may be only moderately affected. These outcomes can be used to guide patient expectations, as this procedure may be necessary in certain salvage scenarios.

The purpose of this systematic review was to report outcomes after bilateral shoulder arthroplasty including bilateral total shoulder arthroplasty (TSA), bilateral reverse shoulder arthroplasty (RSA), and ipsilateral TSA with contralateral RSA (TSA/RSA).Two reviewers independently performed a PRISMA-guided systematic search using MEDLINE/PubMed, Embase, and Cochrane Database of Systematic Reviews up to May 11, 2021. The databases were queried using the following search terms: (("bilateral" OR "contralateral") AND "shoulder" AND ("arthroplast*" OR "replacement")). A total of 486 titles/abstracts were screened for eligibility and 19 studies were included in the final analysis. Risk of bias was assessed using MINORS and MCMS scores. Analysis compared overall results for bilateral shoulder arthroplasty and sub-group analyses compared TSA (all shoulders from bilateral TSA patients and the TSA shoulder in TSA/RSA patients) to RSA (all shoulders from bilateral RSA patients and the RSA shoulder in TSA/RSA patients), first shoulder arthroplasty to second contralateral shoulder arthroplasty, and interval between arthroplasty (IBA)20 months to IBA ≥ 20 months.Nineteen studies analyzed bilateral TSA (n=3), bilateral RSA (n=7), and TSA/RSA (n=8). The mean MINORS was 18 and mean MCMS was 74, with 63.2% of studies demonstrating level III evidence. A total of 2,729 patients (30.4% male; mean age 72.2 years, mean follow-up 47.3 months, mean IBA 20 months) were analyzed. Postoperative forward flexion (142.0˚ vs. 129.6˚), external rotation (42.5˚ vs. 25.6˚), and internal rotation (60% reaching T12-T8 vs. 85.7% reaching L3-L1) were higher for TSA when compared to RSA. Patient reported outcome measures such as Constant-Murley (73.2 vs. 59.2), ASES (87.9 vs. 77.7), and SANE (86.9 vs. 67.8) were higher for TSA when compared to RSA. Patients with IBA ≥20 months demonstrated greater external rotation and patient satisfaction than patients with IBA20 months. Postoperative complication rates were 15.1% for TSA and 10.6% for RSA, while reoperation and revision rates were 13.7% for TSA and 7.1% for RSA.Bilateral shoulder arthroplasty results in improvements in motion, strength, pain, and function, and high satisfaction. Bilateral TSA is associated with greater improvement in motion and function than bilateral RSA, but higher complication, reoperation, and revision rates. IBA20 months is associated with greater ER and satisfaction than IBA20 months.

Perioperative music decreases pain, anxiety, and analgesia requirements while increasing patient satisfaction. We investigated the acceptability of perioperative music at a women’s and children’s hospital in Singapore, seeking to uncover barriers and facilitators to implementation in routine practice over a 12-week period. We used an undergraduate-led Rapid Qualitative Inquiry approach that includes data collection from multiple sources, iterative analysis, and additional data collection when necessary. Participants consisted of anesthesiologists and nurses working in the preoperative area, operating room, and postoperative recovery areas. In Stage 1, nurses and anesthesiologists answered a survey assessing attitudes and knowledge about perioperative music and attended a presentation introducing the intervention. In Stage 2, the results of the Stage 1 survey were disclosed, and nurses and anesthesiologists completed a second survey (Stage 1 survey questions with an additional query about implementation). Twenty-nine nurses were interviewed with semi-structured questions on barriers and facilitators to implementation. In Stage 3, nurses retook the Stage 2 survey after one month of implementation. The implementation of perioperative music was both acceptable and feasible in Singapore. The nurses’ and anesthesiologists’ acceptability increased over time with mostly positive qualitative feedback. Implementation barriers, including patient interest, timing of patient turnover, and added staff workload, appeared minor and could potentially be overcome by utilizing the intervention in the preoperative instead of postoperative area, deploying music in operating rooms with slower turnover, and evenly distributing staff workload. Local implementation stakeholders may make additional recommendations for scaling-up perioperative music interventions to fit other workflows while improving the patient experience.

Background. The effect of perioperative music listening has been proven to relieve preoperative anxiety and depression, while improving patient satisfaction. However, music listening has not been extensively studied in Singapore. Therefore, the primary aim of our study is to investigate the patient satisfaction towards perioperative music listening in the local setting. The secondary aim is to investigate the effect of perioperative music listening in reducing patient surgery-related anxiety and depression.Methods. After obtaining ethics board approval, we conducted a quasiexperimental study on a cohort of female patients who were undergoing elective minor gynaecological surgeries. Apple iPod Touch™ devices containing playlists of selected music genres and noise-cancelling earphones were given to patients to listen during the preoperative and postoperative periods. Hospital Anxiety and Depression Scale (HADS), EQ-5D-3L questionnaire, music listening preferences, and patient satisfaction surveys were administered. Wilcoxon signed-rank and McNemar’s tests for paired data were used for analysis.Results. 83 patients were analysed with 97.6% of patients in the preoperative period and 98.8% of patients in the postoperative period were satisfied with music listening. The median (IQR [range]) score for preintervention HADS anxiety was 7.0 (6.0 [0–17]), significantly higher than that in postintervention at 2.0 (4.0 [0–12]) (P<0.001). Similarly, there was a significant reduction in preintervention HADS depression as compared to postintervention (P<0.001). These results were corroborated by similar findings from the EQ-5D-3L questionnaire.Conclusion. Perioperative music listening improved patient satisfaction and can reduce patient anxiety and depression. We hope to further investigate on how wider implementation of perioperative music listening could improve patient care.

Background The Oxford Knee Score (OKS); Oxford Hip Score (OHS); Knee injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS JR); and Hip disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) are well-validated and widely used short-form patient-reported outcome measures (PROMs) for assessing outcomes after total knee arthroplasty (TKA) and total hip arthroplasty (THA). We are not aware of the existence of any crosswalks to convert scores between these PROMs. We aimed to develop and validate crosswalks that will permit the comparison of scores between studies using different PROMs and the pooling of results for meta-analyses. Methods We retrospectively analyzed scores from patients (486 in the knee cohort and 340 in the hip cohort) from the Syracuse Orthopedic Specialists Joint Registry who had completed the appropriate PROMs (OKS and KOOS JR in the knee cohort and OHS and HOOS JR in the hip cohort) as the standard of care before undergoing primary TKA or unicompartmental knee arthroplasty (UKA) between January 9, 2016, and June 19, 2017, or primary THA or hip resurfacing between November 29, 2010, and October 30, 2017, or when returning for postoperative care. Using the equipercentile equating method, we created 4 crosswalks: OKS to KOOS JR, KOOS JR to OKS, OHS to HOOS JR, and HOOS JR to OHS. To assess validity, Spearman coefficients were calculated using bootstrapping methods, and means for actual and crosswalk-derived scores were compared. Results There were minimal differences between the means of the known and crosswalk-derived scores. As calculated with the use of bootstrapping methods, Spearman coefficients between the actual and derived scores were strong and positive for both knee arthroplasty crosswalks (0.888 to 0.889; 95% confidence interval [CI], 0.887 to 0.891) and hip arthroplasty crosswalks (0.916 to 0.918; 95% CI, 0.914 to 0.919). Conclusions We successfully created 4 crosswalks that allow conversion of Oxford scores to KOOS and HOOS JR scores and vice versa. These crosswalks will allow harmonization of PROMs assessment regardless of which of the short forms are used, which may facilitate multicenter collaboration or allow sites to switch PROMs without loss of historic comparison data. Level of evidence Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose: To report an unusual case of bilateral recurrent full-thickness macular holes (FTMH) in both eyes of a single patient over a 15-year period, with a total of 3 FTMH in the right eye and 2 in the left eye. Each FTMH was successfully treated with vitreous surgery, resulting in hole closure and visual acuity improvement. Observations: During the previous 15 years, a 59-year-old female developed a total of 3 FTMH in the right eye and 2 FTMH in the left eye. The initial FTMH in each eye was surgically closed with pars plana vitrectomy (PPV), epiretinal membrane (ERM) peeling, 14% C3F8 gas placement, and face down positioning. Subsequent recurrences of FTMH, 2 in the right and 1 in the left, were surgically closed with PPV and ERM peeling and/or indocyanine green-assisted internal limiting membrane peeling, 14% C3F8 gas placement, and face down positioning. Seven years following the last FTMH surgical closure, the patient's best-corrected visual acuity was 20/50 in the right eye and 20/32 in the left eye with no FTMH in either eye. Conclusions and importance: This case illustrates that a rare individual may have more than one recurrent FTMH in both eyes. Final visual outcome can be favorable following closure of more than one recurrent FTMH. Keywords: Macular hole, Recurrent macular hole, Reopening macular hole, Vitrectomy, Internal limiting membrane peel, Optical coherence tomography

BACKGROUND: Although p values are standard for reporting statistical significance of patient-reported outcome measures (PROMs), the shift toward clinically important outcome values, including minimal clinically important difference (MCID) and substantial clinical benefit (SCB), necessitates re-evaluation of the current literature. QUESTIONS/PURPOSES: We sought to answer two questions regarding studies on primary hip arthroscopy performed for the treatment of femoroacetabular impingement syndrome (FAIS). (1) Do such studies reporting statistical significance on common PROMs meet published MCID/SCB thresholds? (2) What proportion of such studies report both statistical and clinical significance? METHODS: We identified four papers published in two journals defining MCID/SCB values on the modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sport (HOS-Sport), international Hip Outcome Tool (iHOT-33), and its short version (iHOT-12) for different groups of FAIS patients undergoing hip arthroscopy. We reviewed these two journals from the dates of publication to the present to identify papers reporting changes in post-operative PROMs. The difference in pre- and post-operative scores on each PROM was calculated and compared to MCID/SCB thresholds. RESULTS: Twelve studies were included. Ten studies (83%) evaluated mHHS (90% met MCID, 50% met SCB), seven (58%) evaluated HOS-ADL (100% met MCID/SCB) and HOS-Sport (100% met MCID, 57% met SCB), and one (8%) evaluated iHOT-33 (met MCID/SCB) and iHOT-12 (met MCID). Most studies met MCID and SCB at both 1- and 2-year timepoints. Of the studies evaluated, 50% reported clinical relevance. CONCLUSIONS: Nearly all studies evaluated met MCID, while fewer met SCB. Only half discussed these clinical measures. It is proposed that all future studies report both statistical and clinical significance as standard best practice. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-020-09759-3) contains supplementary material, which is available to authorized users.

A 57-year-old white woman developed autoimmune retinopathy (AIR) in both eyes associated with bilateral autoimmune sensorineural hearing loss. Laboratory testing was positive for 68kDa (heat-shock protein) and 136kDa (human interstitial retinoid-binding protein). Extensive cancer screening was negative. Spectral-domain optical coherence tomography enhanced depth imaging demonstrated a markedly thickened choroid in both eyes. En face imaging showed a distinctive pattern of granular hyperreflective foveal dots. The concurrent sensorineural hearing loss was thought to be of autoimmune origin and also responded to immunosuppressive treatment. Eyes with non-paraneoplastic, seropositive AIR may have associated increased choroidal thickness. Audiology testing should be considered. [ Ophthalmic Surg Lasers Imaging Retina . 2016;47:362–365.]