Unplanned Excision of Synovial Sarcoma: Factors Associated with Recurrence and Survival.

Background: Synovial sarcoma is rare and may present as a small, slow-growing mass. These tumors are often mistaken as benign and are therefore prone to unplanned and/or non-oncologic excision. We sought to identify the rate of unplanned excision of synovial sarcoma and risk factors for recurrence and survival among this cohort. Methods: The medical records of 246 patients evaluated at a single institution for synovial sarcoma between 1997 and 2022 were retrospectively reviewed. Of these, 87 (35%) underwent unplanned, non-oncologic excision. The mean age of the cohort was 49 years. Primary tumors were located in the extremity (n = 63), abdomen (n = 6), thorax (n = 7), head/neck (n = 8), and paraspinal region (n = 3). The median maximum pre-treatment dimension of the primary tumor was 4.8 cm (IQR 7-2.4). Seventy-seven (86%) patients underwent re-excision of the tumor bed, 39 (45%) received chemotherapy, and 63 (72%) received radiation therapy. Results: Among patients who underwent unplanned excision, local recurrence-free survival (LRFS) was 98% at 1 year and 82% at 5 years. Metastasis-free survival (MFS) was 91% at 1 year and 72% at 5 years. Disease-specific survival (DSS) was 98% at 1 year and 72% at 5 years. When adjusting for tumor size, tumors which underwent unplanned excision did not have worse recurrence or survival compared to those which had planned excision (p > 0.10). Size > 5 cm, monophasic subtype, and axial location were associated with increased risk of disease recurrence. Forty-six patients had residual tumor following re-excision, which was associated with worse MFS (HR 8.17, 95% CI [1.89, 35.2], p < 0.01) and DSS (HR 7.66, 95% CI [1.76, 33.4], p < 0.01). Patients who received radiotherapy had improved MFS (HR 6.4, 95% CI [1.42, 29.0], p = 0.02) and DSS (HR 5.86, 95% CI [1.27, 26.9], p = 0.02). Conclusions: One-third of patients presenting with synovial sarcoma were diagnosed after unplanned, non-oncologic excision. Patients with large, axial tumors had worse survival. Approximately half of patients who underwent unplanned excision had no residual tumor after pre-operative radiation. The use of radiation was associated with decreased rates of recurrence and improved disease-specific survival. Our results suggest that margin-negative re-resection and radiotherapy should be considered when feasible following unplanned excision of synovial sarcoma.

Resiliency Does Not Correlate With Outcome Scores After Meniscectomy.

BACKGROUND: Resilience is a psychometric parameter defined as one's ability to recover or bounce back from stressful events and has been shown to correlate with better outcomes following multiple orthopedic procedures. The purpose of this study was to analyze the correlation between resiliency, as measured using the Brief Resiliency Scale (BRS) and various knee outcome scores, including the International Knee Documentation Committee (IKDC), Lysholm, Single Assessment Numeric Evaluation (SANE), and Return to Work, following isolated partial meniscectomy. METHODS: One hundred patients who had undergone an isolated partial meniscectomy during a 3-year period at a single institution were successfully recruited to participate in the study. The BRS and knee outcome scores (IKDC, Lysholm, SANE, Return to Work) were obtained via phone. Radiographs for each patient were obtained and graded for arthritis severity using the Kellgren-Lawrence classification system. RESULTS: Brief Resiliency Scale scores ranged 15.0 to 23.0 with a mean of 18.2 ± 1.3. Mean knee outcome scores for IKDC, Lysholm, SANE, and Return to Work were 66.3, 77.1, 70.6, and 41.0, respectively. Outcome scores did not correlate with BRS scores. The severe arthritis group significantly correlated (p < 0.05) with worse IKDC, Lysholm, and Return to Work scores compared to mild arthritis scores. Additionally, analysis of the mild arthritis group revealed that resiliency significantly correlated with higher Return to Work scores compared to low resilience groups. CONCLUSION: This study suggests that there is no significant relationship between patient resiliency and outcomes following partial meniscectomy. However, those with poorer outcomes had more severe arthritis.

Comparison of reconstructive techniques for nonprimary malignancies in the proximal humerus.

BACKGROUND: Endoprostheses (EPC) are often utilized for reconstruction of the proximal humerus with either hemiarthroplasty (HA) or reverse arthroplasty (RA) constructs. RA constructs have improved outcomes in patients with primary lesions, but no studies have compared techniques in metastatic disease. The aim of this study is to compare functional outcomes and complications between HA and RA constructs in patients undergoing endoprosthetic reconstruction for proximal humerus metastases. METHODS: We retrospectively reviewed our institutional arthroplasty database to identify 66 (56% male; 38 HA and 28 RA) patients with a proximal humerus reconstruction for a non-primary malignancy. The majority (88%) presented with pathologic fracture, and the most common diagnosis was renal cell carcinoma (48%). RESULTSS: Patients with RA reconstructions had better postoperative forward elevation (74° vs. 32°, p < 0.01) and higher functional outcome scores. HA patients had more complications (odds ratio 13, p < 0.01), with instability being the most common complication. CONCLUSIONS: Patients with nonprimary malignancies of the proximal humerus had improved functional outcomes and fewer complications after undergoing reconstruction with a reverse EPC compared to a HA EPC. Preference for reverse EPC should be given in patients with good prognosis and ability to complete postoperative rehabilitation.

Machine learning can accurately predict risk factors for all-cause reoperation after ACLR: creating a clinical tool to improve patient counseling and outcomes.

PURPOSE: Identifying predictive factors for all-cause reoperation after anterior cruciate ligament reconstruction could inform clinical decision making and improve risk mitigation. The primary purposes of this study are to (1) determine the incidence of all-cause reoperation after anterior cruciate ligament reconstruction, (2) identify predictors of reoperation after anterior cruciate ligament reconstruction using machine learning methodology, and (3) compare the predictive capacity of the machine learning methods to that of traditional logistic regression. METHODS: A longitudinal geographical database was utilized to identify patients with a diagnosis of new anterior cruciate ligament injury. Eight machine learning models were appraised on their ability to predict all-cause reoperation after anterior cruciate ligament reconstruction. Model performance was evaluated via area under the receiver operating characteristics curve. To explore modeling interpretability and radiomic feature influence on the predictions, we utilized a game-theory-based method through SHapley Additive exPlanations. RESULTS: A total of 1400 patients underwent anterior cruciate ligament reconstruction with a mean postoperative follow-up of 9 years. Two-hundred and eighteen (16%) patients experienced a reoperation after anterior cruciate ligament reconstruction, of which 6% of these were revision ACL reconstruction. SHapley Additive exPlanations plots identified the following risk factors as predictive for all-cause reoperation: diagnosis of systemic inflammatory disease, distal tear location, concomitant medial collateral ligament repair, higher visual analog scale pain score prior to surgery, hamstring autograft, tibial fixation via radial expansion device, younger age at initial injury, and concomitant meniscal repair. Pertinent negatives, when compared to previous studies, included sex and timing of surgery. XGBoost was the best-performing model (area under the receiver operating characteristics curve of 0.77) and outperformed logistic regression in this regard. CONCLUSIONS: All-cause reoperation after anterior cruciate ligament reconstruction occurred at a rate of 16%. Machine learning models outperformed traditional statistics and identified diagnosis of systemic inflammatory disease, distal tear location, concomitant medial collateral ligament repair, higher visual analog scale pain score prior to surgery, hamstring autograft, tibial fixation via radial expansion device, younger age at initial injury, and concomitant meniscal repair as predictive risk factors for reoperation. Pertinent negatives, when compared to previous studies, included sex and timing of surgery. These models will allow surgeons to tabulate individualized risk for future reoperation for patients undergoing anterior cruciate ligament reconstruction. LEVEL OF EVIDENCE: III.

Comparison of Fixation Techniques for Lower Extremity Rotationplasty.

BACKGROUND: Rotationplasty is a reconstructive, limb-sparing surgery indicated for patients with lower extremity musculoskeletal tumors. The procedure involves rotation of the distal lower extremity to allow the ankle to function as the new knee joint and provide an optimum weight-bearing surface for prosthetic use. Historically there is limited data comparing fixation techniques. The purpose of this study is to compare clinical outcomes between intramedullary nailing (IMN) and compression plating (CP) in young patients undergoing rotationplasty. METHODS: A retrospective review of 28 patients with a mean age of 10±4 years undergoing a rotationplasty for either a femoral (n=19), tibial (n=7), or popliteal fossa (n=2) tumor was performed. The most common diagnosis was osteosarcoma (n=24). Fixation was obtained with either an IMN (n=6) or CP (n=22). Clinical outcomes of patients undergoing rotationplasty were compared between the IMN and CP groups. RESULTS: Surgical margins were negative in all patients. The mean time to union was 24 months (range 6 to 93). There was no difference in the meantime to the union between patients treated with an IMN versus those with a CP (14±16 vs. 27±26 mo, P =0.26). Patients undergoing fixation with an IMN were less likely to have a nonunion (odds ratio: 0.35, 95% confidence interval: 0.03-3.54, P =0.62). Postoperative fracture of the residual limb only occurred in patients undergoing CP fixation (n=7, 33% vs. n=0, 0%, P =0.28). Postoperative fixation complications occurred in 13 (48%) patients, most commonly a nonunion (n=9, 33%). Patients undergoing fixation with a CP were more likely to have a postoperative fixation complication (odds ratio: 20, 95% CI: 2.14-186.88, P <0.01). CONCLUSIONS: Rotationplasty is an option for limb salvage for young patients with lower extremity tumors. The results of this study reveal fewer fixation complications when an IMN can be used. As such, IMN fixation should be considered for patients undergoing a rotationplasty, though equipoise should be shown by surgeons when determining technique.

Pedicled Functional Latissimus Flaps for Reconstruction of the Upper Extremity following Resection of Soft-Tissue Sarcomas.

(1) Background: Resection of soft-tissue sarcomas (STS) of the upper extremity can result in substantial functional impairment with limited options for functional reconstruction. Free functional latissimus flaps have been utilized to restore function of the thigh; however, there is limited data on the use of latissimus flaps for functional reconstruction in the upper extremity. As such, we sought to evaluate our institutional experience with these flaps. (2) Methods: We reviewed ten (seven male; three female; and a mean age of 63 years) patients undergoing soft-tissue sarcoma resection involving the triceps (n = 4), biceps (n = 4), and deltoid (n = 2) reconstructed with a pedicled functional latissimus flap. All surviving patients had at least 1 year of follow-up, with a mean follow-up of 5 years. (3) Results: The mean elbow range of motion and shoulder elevation were 105° and 150°. The mean Musculoskeletal Tumor Society score was 88%, and the muscle strength was four. Four patients had a recipient site wound complication. There were no flap losses. One patient sustained a radiation-associated humerus fracture 5 years postoperatively, treated nonoperatively. (4) Conclusions: Although early complications are high, pedicled functional latissimus flaps allow for wound coverage, potential space obliteration, and restoration of function in the upper extremity following resection of large soft tissue sarcomas.

Extensor Mechanism Reconstruction for Chronic Patellar Tendon Tears.

OBJECTIVES: Reconstruction for a chronic patellar tendon rupture in a native knee is an uncommon surgical procedure. Although there have been case series investigating patient-reported outcomes, there is no systematic review of these studies to date. The purpose of this review is to synthesize the literature on this procedure to better understand its outcomes, complications, and surgical technique options. METHODS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that reported outcomes and techniques of patellar tendon reconstruction for chronic disruption in native knees. Searches were conducted through MEDLINE using PubMed, Cochrane Database of Systematic Reviews, and clinicaltrials.gov. RESULTS: Ten studies with 103 patients and 105 knees were included. Results for nonnative (arthroplasty) knees were excluded. The mean patient age was 40.3 years, and the mean postsurgical follow-up time was 53.8 months. Of the 105 knees, 75% received a hamstring tendon graft, whereas 13% received a bone-tendon-bone graft and 7% received a whole extensor mechanism allograft. The mean preoperative range of motion was 113.8°, which improved to 126.0° postoperatively. The mean preoperative Lysholm score was 58.6, which improved to 86.0 postoperatively; 100% of patients returned to their normal work activities and 76% returned to their prior level of physical activity. There were no major complications reported in any of the included studies. CONCLUSIONS: Chronic patellar tendon disruption in a native knee is an uncommon injury that can result in significant limitations for patients. Although more research is needed to better elucidate which graft is best, outcomes after patellar tendon reconstruction for chronic tears appear to be satisfactory with current techniques.

Impact of the Percentage of Overlapping Surgery on Patient Outcomes: A Retrospective Cohort Study of 87,000 Surgical Cases.

OBJECTIVES: The primary objective of this study was to analyze the relationship of percentage of surgical overlap with patient outcomes to determine if a detrimental level of overlap exists. BACKGROUND: Overlapping surgery is defined as 1 attending physician supervising 2 or more operative cases simultaneously, without the critical portions of the cases occurring concurrently. To date, no study has examined the relationship of percent overlap, or the percentage of 1 case that is spent overlapping with another, to outcomes, efficiency, safety, and complications. METHODS: This study is a retrospective cohort study conducted at a large tertiary referral center. The primary outcomes of interest included operative duration, in-hospital mortality, 30-day readmission, and patient safety indicators (PSIs). The Cochran-Armitage test for trend was used to evaluate the outcomes of interest. P values of ≤0.05 were considered statistically significant. RESULTS: A total of 87,426 cases were included in this study. There were 62,332 cases without overlap (Group 0), 10,514 cases with 1% to 25% overlap (Group 1), 5303 cases with 26% to 50% overlap (Group 2), 4296 cases with 51% to 75% overlap (Group 3), and 4981 cases with >75% overlap (Group 4). In-hospital mortality decreased as overlap increased ( Ptrend <0.0001). Operative time increased with increasing overlap ( Ptrend <0.0001) while readmission rates showed no statistical significance between groups ( Ptrend =0.5078). Rates of PSIs were lower for Groups 1, 2, and 3 (1.69%, 2.01%, and 2.08%) when compared to Group 0 (2.24%). Group 4 had the highest rate of PSIs at 2.35% ( P =0.0086). CONCLUSION: Overlapping surgery was shown to have reduced in-hospital mortality and similar PSI and readmission rates when compared to nonoverlapping cases. Operative time was shown to increase in overlapping surgeries when compared to nonoverlapping surgeries. The results from this study indicate that the percentage of surgical overlap does not detrimentally affect most patient outcomes, especially with overlap of <75%.

Management of Proximal Humeral Oncologic Lesions.

The proximal humerus is a common location for primary tumors, benign lesions, and metastatic disease. Advances in neoadjuvant and adjuvant therapy have allowed for limb-salvage surgery in most of the cases. There are numerous of options for surgical management of proximal humerus lesions and the decision to pursue one over another depends on factors such as age, comorbidities, pathology, location within the proximal humerus, planned resection margins/size of defect, and bone quality. Long-term outcomes for these techniques tend to be retrospective comparative studies, with recent studies highlighting the improved outcomes of reverse total shoulders.

Variability in the Processing of Fresh Osteochondral Allografts.

The indications for fresh osteochondral allograft continue to increase. As a result, variations in graft processing and preservation methods have emerged. An understanding of these techniques is important when evaluating the optimal protocol for processing fresh osteochondral allografts prior to surgical implantation. The aim of this study is to review the literature and understand various tissue processing protocols of four leading tissue banks in the United States. Donor procurement, serological and microbiological testing, and storage procedures were compared among companies of interest. Similarities between the major tissue banks include donor screening, aseptic processing, and testing for microorganisms. Variability exists between these companies with relation to choice of storage media, antibiotic usage, storage temperature, and graft expiration dates. Potential exists for increased chondrocyte viability and lengthened time-to-expiration of the graft through a protocol of delicate tissue handling, proper choice of storage medium, adding hormones and growth factors like insulin growth factor-1 (IGF-1) to serum-free nutrient media, and storing these grafts closer to physiologic temperatures.

Advances in the Treatment of Rotator Cuff Tears: Management of Rotator Cuff Tears in the Athlete.

Unique biomechanical factors in the overhead and throwing athlete lead to a spectrum of rotator cuff pathology, usually with progressive lateralization of the supraspinatus footprint. Initial comprehensive nonoperative management is indicated for all athletes. Progression to arthroscopic debridement, repair of concomitant injuries, and possible rotator cuff repair with a transosseous equivalent technique are the current management strategies for athletes when nonoperative management fails.

Risk factors for secondary meniscus tears can be accurately predicted through machine learning, creating a resource for patient education and intervention.

PURPOSE: This study sought to develop and internally validate a machine learning model to identify risk factors and quantify overall risk of secondary meniscus injury in a longitudinal cohort after primary ACL reconstruction (ACLR). METHODS: Patients with new ACL injury between 1990 and 2016 with minimum 2-year follow-up were identified. Records were extensively reviewed to extract demographic, treatment, and diagnosis of new meniscus injury following ACLR. Four candidate machine learning algorithms were evaluated to predict secondary meniscus tears. Performance was assessed through discrimination using area under the receiver operating characteristics curve (AUROC), calibration, and decision curve analysis; interpretability was enhanced utilizing global variable importance plots and partial dependence curves. RESULTS: A total of 1187 patients underwent ACLR; 139 (11.7%) experienced a secondary meniscus tear at a mean time of 65 months post-op. The best performing model for predicting secondary meniscus tear was the random forest (AUROC = 0.790, 95% CI: 0.785-0.795; calibration intercept = 0.006, 95% CI: 0.005-0.007, calibration slope = 0.961 95% CI: 0.956-0.965, Brier's score = 0.10 95% CI: 0.09-0.12), and all four machine learning algorithms outperformed traditional logistic regression. The following risk factors were identified: shorter time to return to sport (RTS), lower VAS at injury, increased time from injury to surgery, older age at injury, and proximal ACL tear. CONCLUSION: Machine learning models outperformed traditional prediction models and identified multiple risk factors for secondary meniscus tears after ACLR. Following careful external validation, these models can be deployed to provide real-time quantifiable risk for counseling and timely intervention to help guide patient expectations and possibly improve clinical outcomes. LEVEL OF EVIDENCE: III.

Managing Shoulder Instability in the Overhead Athlete.

PURPOSE OF REVIEW: Shoulder instability in the overhead athlete is a difficult problem because of the balance between necessary laxity for athletic movements and stability of the joint. The purpose of this review is to provide an overview of the clinical evaluation of shoulder instability in the overhead athlete and present evidence-based management strategies for each subtype of shoulder instability, including novel techniques and outcomes. RECENT FINDINGS: Recent investigation has shown that throwers and other overhead athletes are more likely to present with subtle subluxation events rather than discrete dislocations as their primary symptom. While overhead athletes with discrete anterior dislocation events are likely to begin with non-operative management, many progress on to surgical intervention. Surgical management of glenohumeral joint instability continues to pose challenges due to the potential for over-tensioning for the sake of stability at the expense of the adaptive laxity that often confers performance benefits in the overhead athlete. Novel, individualized, and sport/position specific approaches are needed to address this complex issue. The optimal management of shoulder instability in the overhead athlete continues to be a controversial topic due to the complex work-up, an increasing number of surgical options with varying indications, and low volume of high-quality studies comparing any of the treatment options. The Anterior Shoulder Instability International Consensus Group guidelines from February 2022 offer the most updated guidelines on work-up and management. Overall, high-quality randomized controlled trials are required to determine the optimal treatment for specific pathologies and aid in creating patient-centered management plans.

Postinterview Communication in Orthopaedic Surgery Residency Interviews: A Survey of Match Applicants.

Background: To maintain the integrity of the match, postinterview communication (PIC) from programs to applicants is monitored and discouraged. The most recent report on the prevalence of PIC in orthopaedics found that 64% of surveyed applicants in 2014 and 2015 had received some form of PIC during their match cycle. In July 2019, the American Orthopaedic Association's Council of Orthopaedic Residency Directors (AOA/CORD) released a guideline recommending the elimination of all PIC in any form. The goal of this follow-up study was to determine the current prevalence of PIC with orthopaedic surgery applicants and assess the perspectives of medical students who recently applied for orthopaedic surgery residency positions. Methods: A 35-question survey was e-mailed to all orthopaedic surgery residency applicants of 4 geographically diverse residency programs in postmatch March 2020. The survey was open for 1 month, and the responses were reported using descriptive statistics. Results: Of the 229 respondents (21% response rate), 91 (39.7%) received PIC during the 2019 to 2020 residency match cycle. The program director was most commonly identified (80.2%) as the person who communicated with the applicants. At the interview day, 198 respondents (86.5%) were told that programs would not be contacting the applicants with PIC. However, over a quarter of respondents (25.3%) who received PIC answered that those programs contacted applicants after announcing they would not. Nearly half of the respondents (48.5%) agreed or strongly agreed that PIC causes added stress on applicants, and over half (52.9%) agreed or strongly agreed that all programs should stop participating in any form of PIC. Conclusions: Although the prevalence of PIC seems to have decreased since the 2014 and 2015 match, there is still room for improvement toward eliminating PIC. The AOA/CORD position statement from July 2019 should be disseminated to all members of the residency selection team to ensure consistency from all programs. The primary limitation of this study was the 21% response rate. Level of Evidence: Level IV (survey study).

Financial Literacy in Orthopaedic Surgery Residents: A COERG Survey.

INTRODUCTION: Financial literacy is the individual ability and skill to make informed decisions in the management of resources within the financial marketplace to yield a lifetime of financial well-being. Residents across several subspecialties have demonstrated low levels of financial literacy, and it is thought that more financial education is needed during residency training. The purpose of this study is to perform a comprehensive evaluation on financial literacy and financial attitudes of orthopaedic surgery residents. The authors hypothesize that orthopaedic residents will have low levels of financial literacy and financial satisfaction. METHODS: A 46-question anonymous survey was administered through COERG (Collaborative Orthopaedic Educational Research Group) to 1028 orthopaedic surgery residents of all postgraduate year at 43 programs with broad national distribution. Resident demographics and survey responses regarding knowledge of finance and investment topics, application of financial principles, and personal financial status were compared. RESULTS: The survey response rate was 48% (494/1028). The average financial literacy score of all orthopaedic resident participants was 60.9% (±16.5%). A total of 35.5% of orthopaedic residents were satisfied with their current financial situation. Saving for retirement and lower loan burdens correlated with greater financial satisfaction in financial situation. Scores were higher in orthopaedic residents with greater childhood annual household income, no credit card debt, higher levels of parent education, and active retirement savings plans. CONCLUSIONS: Orthopaedic residents show significant deficits in overall financial and investment knowledge combined with a dissatisfaction with financial situations while in residency. Orthopaedic residency programs have the opportunity to implement program-sponsored training and financial resources to enhance the resident education experience.

The US Medical Licensing Examination Step 1 Scoring Change: A Survey of Orthopaedic Surgery Residency Applicants From the 2019 to 2020 Match Cycle.

INTRODUCTION: The USMLE Step 1 examination has been used as an objective measure for comparing residency applicants. Recently, the National Board of Medical Examiners and the Federation of State Medical Boards decided that the USMLE Step 1 examination will transition to a pass/fail result starting no earlier than 2022. The purpose of this study was to investigate the perspective of medical students who applied for orthopaedic surgery residency positions during the 2019 to 2020 interview cycle on the USMLE scoring change, and the potential effect this change may result in for future applicants and the residency selection process. METHODS: A 15-item anonymous web-based survey was sent to 1,090 orthopaedic surgery residency applicants from four regionally diverse residency programs. The survey elicited attitudes toward the transition of the Step 1 examination to pass/fail and perspectives this change may or may not have on the residency selection process. RESULTS: Responses were received from 356 applicants (32.7%). The majority (61.6%) disagreed with the change to pass/fail scoring, and 68.5% do not believe that the change will decrease stress levels in medical students. For interview invitations, respondents chose Step 2 clinical knowledge, letters of recommendation, and performance on away rotations as the most influential factors in the absence of a Step 1 score. CONCLUSION: Most of the students surveyed who applied for an orthopaedic surgery residency position during the most recent application cycle disagreed with the National Board of Medical Examiner/Federation of State Medical Board decision to change Step 1 to pass/fail and feel that this change may have disadvantage in certain student groups while either increasing or having no effect on medical student stress. LEVEL OF EVIDENCE: IV.

Quality Improvement Tools in Total Joint Arthroplasty: A Systematic Review.

Systems review and quality improvement (QI) is a significant need within orthopaedic surgery. The focus of this paper is to systematically review QI principles utilized in total joint arthroplasty to determine most successful QI tools. A systematic search on MEDLINE/Pubmed, Embase, Cochrane Library and other sources was conducted from September 1991 through October 2018. The three primary improved outcomes from each article were recorded along with the date, author and subspecialty. Thirty-four eligible studies related to joint arthroplasty were identified for inclusion in the systematic review. The most common outcomes that were improved in these publications were: length of stay (LOS), cost, medication management, and patient education. Lean, clinical care pathways (CCP), plan-do-check-act (PDCA), and shared decision-making improved those metrics. Four metrics were found that were consistently improved by certain quality improvement tools: LOS, cost, medication management, and patient education. Further research is warranted to continue to build a framework for quality improvement in orthopaedic surgery. (Journal of Surgical Orthopaedic Advances 30(3):125-130, 2021).

Physical Therapy-Induced Fracture After Reverse Shoulder Arthroplasty: A Case Report.

CASE: We present a case of a physical therapy-induced fracture of the proximal humerus, presumably caused by forceful shoulder flexion and external rotation, after reverse total shoulder arthroplasty (RTSA) in a 70-year-old woman with underlying osteopenia, systemic lupus erythematosus, long-term glucocorticoid use, and common variable immunodeficiency. CONCLUSION: This case of a physical therapy-induced greater tuberosity fracture after RTSA presents an example of an early postoperative complication with no impact on eventual successful surgical outcomes. Special consideration should be given to tailor the postoperative rehabilitation after RTSA in patients with increased risk of fractures.