Assessing Shoulder Biomechanics of Healthy Elderly Individuals During Activities of Daily Living Using Inertial Measurement Units: High Maximum Elevation Is Achievable but Rarely Used.

Current shoulder clinical range of motion (ROM) assessments (e.g., goniometric ROM) may not adequately represent shoulder function beyond controlled clinical settings. Relative inertial measurement unit (IMU) motion quantifies ROM precisely and can be used outside of clinic settings capturing "real-world" shoulder function. A novel IMU-based shoulder elevation quantification method was developed via IMUs affixed to the sternum/humerus, respectively. This system was then compared to in-laboratory motion capture (MOCAP) during prescribed motions (flexion, abduction, scaption, and internal/external rotation). MOCAP/IMU elevation were equivalent during flexion (R2 = 0.96, µError = 1.7 deg), abduction (R2 = 0.96, µError = 2.9 deg), scaption (R2 = 0.98, µError = -0.3 deg), and internal/external rotation (R2 = 0.90, µError = 0.4 deg). When combined across movements, MOCAP/IMU elevation were equal (R2 = 0.98, µError = 1.4 deg). Following validation, the IMU-based system was deployed prospectively capturing continuous shoulder elevation in 10 healthy individuals (4 M, 69 ± 20 years) without shoulder pathology for seven consecutive days (13.5 ± 2.9 h/day). Elevation was calculated continuously daily and outcome metrics included percent spent in discrete ROM (e.g., 0-5 deg and 5-10 deg), repeated maximum elevation (i.e., >10 occurrences), and maximum/average elevation. Average elevation was 40 ± 6 deg. Maximum with >10 occurrences and maximum were on average 145-150 deg and 169 ± 8 deg, respectively. Subjects spent the vast majority of the day (97%) below 90 deg of elevation, with the most time spent in the 25-30 deg range (9.7%). This study demonstrates that individuals have the ability to achieve large ROMs but do not frequently do so. These results are consistent with the previously established lab-based measures. Moreover, they further inform how healthy individuals utilize their shoulders and may provide clinicians a reference for postsurgical ROM.

Mapping the Diffusion of Technology in Orthopaedic Surgery: Understanding the Spread of Arthroscopic Rotator Cuff Repair in the United States.

BACKGROUND: The mechanism by which surgical innovation is spread in orthopaedic surgery is not well studied. The recent widespread transition from open to arthroscopic rotator cuff repair techniques provides us with the opportunity to study the spread of new technology; doing so would be important because it is unclear how novel orthopaedic techniques disseminate across time and geography, and previous studies of innovation in healthcare may not apply to the orthopaedic community. QUESTIONS/PURPOSES: (1) How much regional variation was associated with the adoption of arthroscopic rotator cuff repair in the United States Medicare population between 2006 and 2014 and how did this change over time? (2) In which regions of the United States was arthroscopic rotator cuff repair first adopted and how did it spread geographically? (3) Which regional factors were associated with the adoption of this new technology? METHODS: We divided the United States into 306 hospital referral regions based upon referral patterns observed in the Centers for Medicare & Medicaid Services MedPAR database, which records all Medicare hospital admissions; this has been done in numerous previous studies using methodology introduced by the Dartmouth Atlas. The proportion of arthroscopic rotator cuff repairs versus open rotator cuff repairs in each hospital referral region was calculated using adjusted procedural rates from the Medicare Part B Carrier File from 2006 to 2014, as it provided a nationwide sample of patients, and was used as a measure of adoption. A population-weighted, multivariable linear regression analysis was used to identify regional characteristics independently associated with adoption. RESULTS: There was substantial regional variation associated with the adoption of arthroscopy for rotator cuff repair as the percentage of rotator cuff repair completed arthroscopically in 2006 ranged widely among hospital referral regions with a high of 85.3% in Provo, UT, USA, and a low of 16.7% in Seattle, WA, USA (OR 30, 95% CI 17.6 to 52.2; p < 0.001). In 2006, regions in the top quartiles for Medicare spending (+9.1%; p = 0.008) independently had higher adoption rates than those in the bottom quartile, as did regions with a greater proportion of college-educated residents (+12.0%; p = 0.009). The Northwest region (-14.4%; p = 0.009) and the presence of an academic medical center (-5.8%; p = 0.026) independently had lower adoption than other regions and those without academic medical centers. In 2014, regions in the top quartiles for Medicare spending (+5.7%; p = 0.033) and regions with a greater proportion of college-educated residents (+9.4%; p = 0.005) independently had higher adoption rates than those in the bottom quartiles, while the Northwest (-9.6%; p = 0.009) and Midwest regions (-5.1%; p = 0.017) independently had lower adoption than other regions. CONCLUSION: The heterogeneous diffusion of arthroscopic rotator cuff repair across the United States highlights that Medicare beneficiaries across regions did not have equal access to these procedures and that these discrepancies continued to persist over time. A higher level of education and increased healthcare spending were both associated with greater adoption in a region and conversely suggest that regions with lower education and healthcare spending may pursue innovation more slowly. There was evidence that regions with academic medical centers adopted this technology more slowly and may highlight the role that private industry and physicians in nonacademic organizations play in surgical innovation. Future studies are needed to understand if this later adoption leads to inequalities in the quality and value of surgical care delivered to patients in these regions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Continuously monitoring shoulder motion after total shoulder arthroplasty: maximum elevation and time spent above 90° of elevation are critical metrics to monitor.

BACKGROUND: Traditional clinical shoulder range-of-motion (ROM) measurement methods (ie, goniometry) have limitations assessing ROM in total shoulder arthroplasty (TSA) patients. Inertial measurement units (IMUs) are superior; however, further work is needed using IMUs to longitudinally assess shoulder ROM before TSA and throughout post-TSA rehabilitation. Accordingly, the study aims were to prospectively capture shoulder elevation in TSA patients and to compare the results with healthy controls. We hypothesized that patients would have reduced maximum elevation before TSA compared with controls but would have improved ROM after TSA. METHODS: A validated IMU-based shoulder elevation quantification method was used to continuously monitor 10 healthy individuals (4 men and 6 women; mean age, 69 ± 20 years) without shoulder pathology and 10 TSA patients (6 men and 4 women; mean age, 70 ± 8 years). Controls wore IMUs for 1 week. Patients wore IMUs for 1 week before TSA, for 6 weeks at 3 months after TSA, and for 1 week at 1 year after TSA. Shoulder elevation was calculated continuously, broken into 5° angle "bins" (0°-5°, 5°-10°, and so on), and converted to percentages. The main outcome measures were binned movement percentage, maximum elevation, and average elevation. Patient-reported outcome measures and goniometric ROM were also captured. RESULTS: No demographic differences were noted between the cohorts. Average elevation was not different between the cohorts at any time. Control maximum elevation was greater than pre-TSA and post-TSA week 1 and week 2 values. Time under 30° and time above 90° were equal between the cohorts before TSA. After TSA, patients showed decreased time under 30° and increased time above 90°. DISCUSSION: This study demonstrates that acute and chronic recovery after TSA can be assessed via maximum elevation and time above 90°, respectively. These results inform how healthy individuals and patients use their shoulders before and after TSA.

Identifying regional characteristics influencing variation in the utilization of rotator cuff repair in the United States.

BACKGROUND: There is a lack of consensus regarding indications for surgical management of rotator cuff disease, which can lead to increased regional variation. The objectives of this study were to describe the geographic variation in rates of rotator cuff repair (RCR) in the United States over time and to identify regional characteristics associated with utilization. METHODS: The United States was divided into 306 hospital referral regions. The adjusted per capita RCR rate was calculated using procedural counts derived from the Medicare Part B Carrier File from 2004-2014. Population-weighted multivariable regression was used to identify regional characteristics independently associated with utilization in 2014. RESULTS: In 2014, an 8-fold difference in rates of RCR was found between regions. Between 2010 and 2014, the overall rate of RCR grew only 3.6% and regional variation decreased. Higher regional utilization of several other orthopedic procedures (P < .02), as well as the regional supply of orthopedic surgeons (P = .002), was independently associated with significantly increased utilization. The South, Southeast, and Southwest were independently associated with significantly higher utilization (P < .001) compared with the Northeast. A higher prevalence of resident physicians, a marker of the academic presence within a region, was independently associated with decreased utilization (P < .001). CONCLUSION: Utilization of RCR has increased substantially over the past decade, but the rate of growth appears to be slowing. RCR remains a procedure with significant regional variation, and increased utilization across regions is associated with higher orthopedic surgeon supply and increased rates of other orthopedic procedures.

Acute versus delayed reverse total shoulder arthroplasty for the treatment of proximal humeral fractures in the elderly population: a systematic review and meta-analysis.

BACKGROUND: Recent literature has shown that acute reverse total shoulder arthroplasty (RTSA) yields good outcomes in the treatment of displaced proximal humeral fractures, and there have also been recent studies showing that delayed RTSA can be successfully used for sequelae of proximal humeral fractures such as nonunion and malunion. The use of meta-analysis affords the opportunity to formally compare the outcomes of acute RTSA for fracture and delayed RTSA for fracture sequelae. METHODS: We searched the MEDLINE, Embase, and Cochrane Library databases. We included all studies reporting on RTSA for the treatment of proximal humeral fracture sequelae with a comparison group of acute RTSA or with no comparison group in adults with a mean age older than 65 years and at least 2 years of follow-up. We calculated weighted mean differences for range of motion, standardized mean differences for clinical outcome scores, and relative risks for dichotomous outcomes. RESULTS: Sixteen studies met the inclusion criteria, which comprised 322 patients undergoing RTSA for fracture sequelae. Of these studies, 4 were comparative (46 patients) whereas 12 were case series (276 patients). Among studies directly comparing acute versus delayed RTSA, no differences in forward flexion (P = .72), clinical outcome scores (P = .78), or all-cause reoperation (P = .92) were found between the 2 groups. Patients undergoing delayed RTSA achieved 6° more external rotation than those undergoing acute RTSA; this difference was significant (P = .01). CONCLUSIONS: Given the risks associated with surgery in the elderly population, consideration may be given to an initial trial of nonoperative treatment in these patients, saving RTSA for those in whom nonoperative treatment fails without compromising the ultimate outcome.

A concise shoulder outcome measure: application of computerized adaptive testing to the American Shoulder and Elbow Surgeons Shoulder Assessment.

BACKGROUND: Patient-reported outcome measures enable quantitative and patient-centric assessment of orthopedic interventions; however, increased use of these forms has an associated burden for patients and practices. We examined the utility of a computerized adaptive testing (CAT) method to reduce the number of questions on the American Shoulder and Elbow Surgeons (ASES) instrument. METHODS: A previously developed ASES CAT system was applied to the responses of 2763 patients who underwent shoulder evaluation and treatment and had answered all questions on the full ASES instrument. Analyses to assess the accuracy of the CAT score in replicating the full-form score included the mean and standard deviation of both groups of scores, frequency distributions of the 2 sets of scores and score differences, Pearson and intraclass correlation coefficients, and Bland-Altman assessment of patterns in score differences. RESULTS: By tailoring questions according to prior responses, CAT reduced the question burden by 40%. The mean difference between CAT and full ASES scores was -0.14, and the scores were within 5 points in 95% of cases (a 12-point difference is considered the threshold for clinical significance) and were clustered around zero. The correlation coefficients were 0.99, and the frequency distributions of the CAT and full ASES scores were nearly identical. The differences between scores were independent of the overall score, and no significant bias for CAT scores was found in either a positive or negative direction. CONCLUSION: The ASES CAT system lessens respondent burden with a negligible effect on score integrity.

Fatigue failure of reverse shoulder humeral tray components of a single design.

BACKGROUND: Modularity in shoulder arthroplasty provides surgical flexibility and facilitates less-complex revision surgery. Modular designs must fit in the glenohumeral joint space, necessitating minimal thickness and careful material selection. The potential for fatigue fracture is higher, and fatigue fracture has been experienced by patients. The purpose of this study was to determine the impact of geometry and materials used for modular humeral trays from a single manufacturer. METHODS: We consecutively retrieved 8 humeral trays of nearly identical designs: 4 Ti-6Al-4V (Ti) and 4 CoCrMo (CoCr). Optical microscopy and scanning electron microscopy were used, along with metallurgical techniques. Finite element and fatigue analyses of the stresses at the humeral tray taper informed observation interpretation. RESULTS: Two Ti devices were revised for in vivo fracture. Scanning electron microscopy showed cracking in the other 2 Ti trays and no evidence of cracking in the CoCr components. A geometric difference in the CoCr devices resulted in a 25% decreased stress under simulated activities of daily living. Accounting for the tray material properties, the fatigue failure envelope ranged from 1000 to 1 million cycles for Ti and from 30,000 to >10 million cycles for CoCr. CONCLUSIONS: All Ti humeral tray retrievals fractured in vivo or were cracked at the taper fillet. No CoCr retrievals showed signs of cracking. Finite element and fatigue analyses predict a 10-fold lifetime increase for the CoCr devices compared with the Ti devices. This study shows that fatigue failure is possible for some reverse shoulder components and is likely exacerbated by fillet radius, tray thickness, and material choice.

Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review.

BACKGROUND: Displaced proximal humeral fractures have traditionally been treated with hemiarthroplasty in older adults, but sometimes hemiarthroplasty results in poor functional outcomes due to rotator cuff deficiency. Reverse shoulder arthroplasty (RSA) can offer potentially improved outcomes in these situations. We assessed the functional outcomes of older adults treated with RSA for proximal humeral fractures compared with hemiarthroplasty. METHODS: We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, and 3 clinical trials registries. We included all studies treating proximal humeral fractures with RSA in adults with a mean age older than 60 years and 1 year of follow-up. We calculated weighted mean differences (WMD) for range of motion and standardized mean differences (SMD) for shoulder scores. Postoperative complications were evaluated qualitatively. RESULTS: Fifteen studies met inclusion criteria, including 377 patients treated with RSA and 504 patients treated with hemiarthroplasty. In controlled studies, the RSA group had improved forward flexion (WMD, 21°;, P = .02) and functional outcome scores (SMD, 0.44; P = .005) compared with the hemiarthroplasty group but decreased external rotation (WMD, -5°; P < .0001). Postoperative complications were similar between the 2 groups. CONCLUSION: RSA results in improved forward flexion and functional outcome scores compared with hemiarthroplasty for older adults with proximal humeral fractures. Complications do not appear to be appreciably higher in the RSA group in the existing follow-up. The results of this review suggest that RSA is a reasonable alternative for treating older adults with proximal humeral fractures, but more research and longer follow-up are needed. LEVEL OF EVIDENCE: Level IV, systematic review.

Current and Future Applications of Fluorescence Guidance in Orthopaedic Surgery.

Fluorescence-guided surgery (FGS) is an evolving field that seeks to identify important anatomic structures or physiologic phenomena with helpful relevance to the execution of surgical procedures. Fluorescence labeling occurs generally via the administration of fluorescent reporters that may be molecularly targeted, enzyme-activated, or untargeted, vascular probes. Fluorescence guidance has substantially changed care strategies in numerous surgical fields; however, investigation and adoption in orthopaedic surgery have lagged. FGS shows the potential for improving patient care in orthopaedics via several applications including disease diagnosis, perfusion-based tissue healing capacity assessment, infection/tumor eradication, and anatomic structure identification. This review highlights current and future applications of fluorescence guidance in orthopaedics and identifies key challenges to translation and potential solutions.

The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy.

BACKGROUND: Hemiarthroplasty (humeral head replacement [HHR]) and reverse shoulder arthroplasty (RSA) are surgical options for cuff tear arthropathy (CTA). RSA may provide better pain relief and functional outcomes, but it costs more and may have a higher complication rate. The goal of this study was to compare the cost-effectiveness of these two treatments and to use sensitivity analysis to determine the drivers of the model. MATERIALS AND METHODS: A Markov decision model was used. Outcome and complication probabilities were obtained from existing literature. Costs were based on average Medicare reimbursement and implant prices. Utilities were derived from responses to health state surveys (Short Form 6D) from 31 patients at one institution who underwent RSA or HHR for CTA. Incremental cost-effectiveness ratios were used to compare treatments. RESULTS: Our model showed RSA could be a cost-effective strategy for treatment of CTA, using $100,000 per quality-adjusted life-year gained as a cutoff and the Short Form 6D for utilities. The model was extremely sensitive to the complication rate and the utility of each procedure and was also sensitive to implant price, with an implant price <$13,000 making RSA cost-effective. CONCLUSIONS: Currently available cost and outcome data show that RSA could be a cost-effective alternative to HHR for CTA. The cost-effectiveness of RSA depends most on the health utility gained from the operation, the utility lost due to complications from the operation, and the cost of the implant. Dropping the implant price to <$7,000 increases cost-effectiveness to <$50,000 per quality-adjusted life-year gained. Further head-to-head studies evaluating the clinical and quality of life outcomes of these two treatments are warranted.

The Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Open Reduction Internal Fixation for Proximal Humerus Fractures in the Elderly.

Background: Open reduction and internal fixation (ORIF) of proximal humerus fractures in elderly individuals (age >70) carries a relatively high short-term complication and reoperation rate but is generally durable once healed. Reverse total shoulder arthroplasty (RTSA) for fractures may be associated with superior short-term quality of life but carries the lifelong liabilities of joint replacement. The tradeoff between short and long-term risks, coupled with disparities in quality of life and cost, makes this clinical decision amenable to cost-effectiveness analysis. Methods: A Markov state-transition model was constructed with a base case of a 75 year-old patient. Reoperation rates, quality of life values, mortality rates, and costs were based upon published literature. The model was run until all patients had died to simulate the accumulated costs and benefits. Results: RTSA was associated with greater quality of life (7.11 QALYs) than ORIF (6.22 QALYs). RTSA was cost-effective with an incremental cost-effectiveness ratio of $3,945/QALY and $27,299/ QALY from payor and hospital perspectives, respectively. RTSA was favored and cost-effective at any age above 65 and any Charlson Score. The model was sensitive to the utility of both procedures. Conclusion: RTSA resulted in a higher quality of life and was cost-effective in comparison to ORIF for elderly patients.Level of Evidence: III.

What rate of utilization is appropriate in musculoskeletal care?

UNLABELLED: Musculoskeletal procedures often show wide variation in rates across geographic areas, which begs the question, "Which rate is right?" Clearly, there is no simple answer to this question. We summarize a conceptual framework for thinking about how to approach this question for different types of interventions. One guiding principle is the "right rate" is usually the one that results from the choices of a fully informed and empowered patient population. For truly effective care without substantial tradeoffs, the right rate may approach 100%. The rate of operative treatment of hip fracture, for example, approaches the underlying incidence of disease; however, the rate of some forms of effective care, like osteoporosis evaluation and treatment after a fragility fracture, is often quite low and undoubtedly reflects underuse. The recommended approach to underuse is to improve the reliability and accountability of the delivery system. Many other musculoskeletal interventions fall into the category of "preference-sensitive care." These interventions involve important tradeoffs between risks and benefits. Variations in these procedure rates may represent insufficient focus on patient values and preferences, relying instead on the enthusiasm of the physician for treatment alternatives. The recommended approach in this setting is the use of decision aids and other approaches to informed choice. LEVEL OF EVIDENCE: Level V, expert opinion. See Guidelines for Authors for a complete description of levels of evidence.

Decreased Reoperations and Improved Outcomes With Reverse Total Shoulder Arthroplasty in Comparison to Hemiarthroplasty for Geriatric Proximal Humerus Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVES: We sought to compare range of motion, clinical outcome scores, and complications after reverse total shoulder arthroplasty (RSA) and hemiarthroplasty (HA) in geriatric patients with acute proximal humerus fractures. DATA SOURCES: We searched MEDLINE (1946-2017), EMBASE (1947-2017), the Cochrane Central Register of Controlled Trials (1898-2017) and ClinicalTrials.gov in October 2017. No limits were used in the database search. We also manually reviewed reference lists of included studies. We did not restrict studies based on language. STUDY SELECTION: We included all randomized controlled trials and cohort studies in which the study population had a mean age of 65 years or older, received RSA or HA to treat an acute proximal humerus fracture, and had a minimum follow-up of 6 months. DATA EXTRACTION: Two independent reviewers used a standardized data collection form to extract relevant information from included studies. Discrepancies were resolved by a consensus or a third party if consensus could not be reached. Study authors were contacted for missing or incomplete data. DATA SYNTHESIS: Using a random effects model, we calculated mean differences (MD) and standardized mean differences (SMD) for continuous outcomes; we calculated relative risk for dichotomous outcomes. RESULTS: Fifteen studies were included in the meta-analysis, including 421 patients treated with RSA and 492 treated with HA for a total of 913 patients. Compared with HA, the RSA group had significantly improved pain scores (SMD = 0.74, P < 0.001), outcome scores (SMD = 0.63, P < 0.001), and forward flexion (MD = 24.3 degrees, P < 0.001). Compared with RSA, the HA group had a significantly increased risk of reoperation (relative risk = 2.8, P = 0.02). There were no differences between the groups with regard to external rotation (P = 0.31) or deep infection (P = 0.90). CONCLUSIONS: Aggregating available research suggests that RSA results in improved range of motion, clinical outcome scores, and rates of all-cause reoperation with no difference in infection rates. Using RSA for the treatment of acute proximal humerus fractures in the elderly population may result in improved short- and medium-term outcomes compared with HA. Future work should evaluate long-term outcomes to see if the benefits of RSA persist. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patterns of Opioid Use in the 12 Months Following Geriatric Fragility Fractures: A Population-Based Cohort Study.

OBJECTIVES: Fractures of the hip, distal radius, and proximal humerus are common in the Medicare population. This study's objective was to characterize patterns and duration of opioid use, including regional variations in use, after both surgical and nonoperative management. DESIGN: Population-based cohort study. SETTING AND PARTICIPANTS: A cohort of opioid-naïve community-dwelling US Medicare beneficiaries who survived a hip, distal radius, or proximal humerus fracture between January 1, 2007 and December 31, 2010. Cohort members were required to be opioid-naïve for 4 months prior to fracture. MEASURES: We analyzed the proportion of patients with an active opioid prescription in each month following the index fracture, and report continued fills at 12 months postfracture. We also compared opioid prescription use in fractures treated surgically and nonsurgically and characterized state-level variation in opioid prescription use at 3 months postfracture. RESULTS: There were 91,749 patients included in the cohort. Hip fracture patients had the highest rate of opioid use at 12 months (6.4%), followed by proximal humerus (5.7%), and distal radius (3.7%). Patients who underwent surgical fixation of proximal humerus and wrist fractures had higher rates of opioid use in each of the first 12 postoperative months compared with those managed nonoperatively. There was significant variation of opioid use at the state level, ranging from 7.6% to 18.2% of fracture patients filling opioid prescriptions 3 months after the index fracture. CONCLUSIONS/IMPLICATIONS: Opioid-naïve patients sustaining fragility fractures of the hip, proximal humerus, or distal radius are at risk to remain on opioid medications 12 months after their index injury, and surgical management of proximal humerus and distal radius fractures increases opioid use in the 12 months after the index fracture. There is significant state-level variation in opiate consumption after index fracture in nonvertebral geriatric fragility fractures. Opportunity exists for targeted quality improvement efforts to reduce the variation in opioid use following common geriatric fragility fractures.

Analysis of polyethylene wear of reverse shoulder components: A validated technique and initial clinical results.

One of the most prevalent phenomena associated with reverse total shoulder arthroplasty (rTSA) is scapular notching. Current methods examine only the damage to the scapula and no methods are available for quantifying the total wear volume of the polyethylene humeral bearing. Quantifying the polyethylene material loss may provide insight into the mechanism for scapular notching and into the particle dose delivered to the patient. A coordinate measurement machine (CMM) and custom computer algorithms were employed to quantify the volumetric wear of polyethylene humeral bearings. This technique was validated using two never-implanted polyethylene humeral liners with a controlled amount of wear in clinically relevant locations. The technique was determined to be accurate to within 10% of the known value and within 5 mm3 of the gravimetrically determined values. Following validation, ten retrieved polyethylene humeral liners were analyzed to determine a baseline for future clinical tests. Four of the ten polyethylene humeral liners showed visible and measureable wear volumes ranging from 40 to 90 mm3 total with a maximum wear rate as high as 470 mm3 /year in one short duration and significantly damaged humeral liner. This validated technique has the potential to relate patient outcomes such as scapular notching grades to polyethylene release into the body. While the total wear volumes are less than reported in literature for cases of osteolysis in knee and hip patients, dosages are well within the osteolytic thresholds that have been suggested, indicating that osteolysis may be a clinical concern in the shoulder. This work provides the basis for future studies that relate volumetric wear to patient outcomes. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:980-987, 2017.

Falling Down on the Job: Evaluation and Treatment of Fall Risk Among Older Adults With Upper Extremity Fragility Fractures.

Background: Clinical practice guidelines recommend fall risk assessment and intervention for older adults who sustain a fall-related injury to prevent future injury and mobility decline. Objective: The aim of this study was to describe how often Medicare beneficiaries with upper extremity fracture receive evaluation and treatment for fall risk. Design: Observational cohort. Methods: Participants were fee-for-service beneficiaries age 66 to 99 treated as outpatients for proximal humerus or distal radius/ulna ("wrist") fragility fractures. -Participants were studied using Carrier and Outpatient Hospital files. The proportion of patients evaluated or treated for fall risk up to 6 months after proximal humerus or wrist fracture from 2007-2009 was examined based on evaluation, treatment, and diagnosis codes. Time to evaluation and number of treatment sessions were calculated. Logistic regression was used to analyze patient characteristics that predicted receiving evaluation or treatment. Narrow (gait training) and broad (gait training or therapeutic exercise) definitions of service were used. Results: There were 309,947 beneficiaries who sustained proximal humerus (32%) or wrist fracture (68%); 10.7% received evaluation or treatment for fall risk or gait issues (humerus: 14.2%; wrist: 9.0%). Using the broader definition, the percentage increased to 18.5% (humerus: 23.4%; wrist: 16.3%). Factors associated with higher likelihood of services after fracture were: evaluation or treatment for falls or gait prior to fracture, more comorbidities, prior nursing home stay, older age, humerus fracture (vs wrist), female sex, and white race. Limitations: Claims analysis may underestimate physician and physical therapist fall assessments, but it is not likely to qualitatively change the results. Conclusions: A small proportion of older adults with upper extremity fracture received fall risk assessment and treatment. Providers and health systems must advance efforts to provide timely evidence-based management of fall risk in this population.

Patterns of Prescription Drug Use Before and After Fragility Fracture.

IMPORTANCE: Patients who have a fragility fracture are at high risk for subsequent fractures. Prescription drugs represent 1 factor that could be modified to reduce the risk of subsequent fracture. OBJECTIVE: To describe the use of prescription drugs associated with fracture risk before and after fragility fracture. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study conducted between February 2015 and March 2016 using a 40% random sample of Medicare beneficiaries from 2007 through 2011 in general communities throughout the United States. A total of 168 133 community-dwelling Medicare beneficiaries who survived a fracture of the hip, shoulder, or wrist were included. Cohort members were required to be enrolled in fee-for-service Medicare with drug coverage (Parts A, B, and D) and to be community dwelling for at least 30 days in the immediate 4-month postfracture period. EXPOSURES: Prescription drug use during the 4-month period before and after a fragility fracture. MAIN OUTCOMES AND MEASURES: Prescription fills for drug classes associated with increased fracture risk were measured using Part D retail pharmacy claims. These were divided into 3 categories: drugs that increase fall risk; drugs that decrease bone density; and drugs with unclear fracture risk mechanism. Drugs that increase bone density were also tracked. RESULTS: A total of 168 133 patients with a fragility fracture (141 569 women; 84.2%) met the inclusion criteria for this study; 91.8% were white. Across all fracture types, the mean (SD) age was 80.0 (7.7) years, and 53.2% of the fracture cohort was hospitalized at the time of the index fracture, although this varied significantly depending on fracture type (100% of hip fractures, 8.2% of wrist fractures, and 15.0% of shoulder fractures). The frequency of discharge to an institution for rehabilitation following hospitalization also varied by fracture type, but the mean (SD) duration of acute rehabilitation did not: 28.1 (19.8) days. Most patients were exposed to at least 1 nonopiate drug associated with increased fracture risk in the 4 months before fracture (77.1% of hip, 74.1% of wrist, and 75.9% of shoulder fractures). Approximately 7% of these patients discontinued this drug exposure after the fracture, but this was offset by new users after fracture. Consequently, the proportion of the cohort exposed following fracture was unchanged (80.5%, 74.3%, and 76.9% for hip, wrist, and shoulder, respectively). There was no change in the average number of fracture-associated drugs used. This same pattern of use before and after fracture was observed across all 3 drug mechanism categories. Use of drugs to strengthen bone density was uncommon (≤25%) both before and after fracture. CONCLUSIONS AND RELEVANCE: Exposure to prescription drugs associated with fracture risk is infrequently reduced following fragility fracture occurrence. While some patients eliminate their exposure to drugs associated with fracture, an equal number initiate new high-risk drugs. This pattern suggests there is a missed opportunity to modify at least one factor contributing to secondary fractures.

Adverse reactions to OsteoSet bone graft substitute, the incidence in a consecutive series.

BACKGROUND: The purpose of this study was to identify factors that may be associated with the development of a sterile inflammatory reaction to OsteoSet (Wright Medical Technology) bone graft substitute. We report on a series of 58 consecutive cases of patients with benign bone lesions who developed an adverse reaction to Osteoset. All procedures were performed by a single orthopaedic oncology surgeon. METHODS: Patients who exhibited an adverse reaction to OsteoSet and those who did not were analyzed for statistical differences with respect to age, sex, volume of graft material used, size of pellet, use of alcohol washes, mixing of OsteoSet with allograft, medications, drug allergies, and smoking history. Comparisons were made between the reaction group and the non-reaction group with respect to the these variables. RESULTS: Eight definite (13.8%) and 3 probable (5.2%) reactions were identified. Symptoms developed an average of 38.9 days after the operation. There was no statistically significant difference (p>0.05) in the volume of Osteoset used, size of pellet, use of alcohol washes, mixing of OsteoSet with allograft, patient age, sex, drug allergies, or smoking history. Reported use of at least one medication was statistically significant between groups when probable reactions were included with the non-reaction group (p < 0.05), but not when probables were analyzed with the definite reaction group ( p < 0.10). A review of our patients' medication lists did not reveal any single or combination of medications likely to be responsible for this difference. Type and location of tumor also did not appear to differ significantly between the two groups. CONCLUSIONS: Although we report a 13.8%-19.0% incidence of adverse reaction to OsteoSet, we are unable to identify any statistically significant factors that might predict the development of a reaction. Fortunately, the reaction is essentially self limited and fairly benign requiring only anti-inflammatories and observation.

Use of the spider limb positioner in oncologic lower extremity surgery.

Orthopedic extremity surgery presents a unique set of restraints and difficulties relative to other surgical specialties. Among these is the positioning of heavy limbs in sometimes awkward positions for long periods of time. Ideal positioning of an extremity allows accurate and precise surgery to occur at otherwise difficult to access joints and proximal bones and soft tissues. Numerous solutions to this problem have been proposed, one such solution is the Smith and Nephew Spider Limb Positioning System. The table-mounted pneumatic arm features three fully articulating joints and a simple repositioning mechanism. Classic uses of the Spider Limb Positioner System include shoulder and elbow surgery, total knee replacement and ankle procedures. In our institution, the Spider Limb Positioner is used primarily for shoulder arthroscopy and total shoulder arthroplasty. In addition, we have had success using the system for orthopedic oncology cases. This manuscript addresses the conventional as well as unconventional uses implemented at our institution. Limb positioning in orthopedics provides a unique challenge for prepping, draping and surgery. The use of positioning aids can improve exposure, decrease contamination and reduce the risk of surgeon strain. Our institution has developed a solution to positioning of heavy lower limbs for hip disarticulation via the Smith and Nephew 'Spider'. This pneumatic, full articulating device used primarily for shoulder surgery can be modified to allow lower extremity use in the setting of hip disarticulation. This paper describes the standard and novel use of this device.

Functional improvement after humeral shaft nonunion in a patient with glenohumeral ankylosis.

Functionally limiting heterotopic ossification about the shoulder represents an uncommon clinical entity, which has been most commonly reported as a consequence of prolonged immobilization in intensive care unit patients. Severe cases may result in complete glenohumeral ankylosis, with resultant upper extremity motion through the scapulothoracic joint, and significant functional consequences. We report the case of a 72-year-old male with spontaneous glenohumeral ankylosis who suffered a humeral shaft fracture with resultant painless nonunion. Motion through the nonunion site caused significant subjective functional improvements, increased range of motion, and the ability to complete his activities of daily living. Patients with limited shoulder range of motion may be at higher risk for humeral fractures and nonunion. These patients, however, may experience improved function due to increased upper extremity range of motion through the nonunion site.