Intraoperative posture and workload assessment in vascular surgery.

Quantifying the workload and postural demand on vascular surgeons provides valuable information on the physical and cognitive factors that predispose vascular surgeons to musculoskeletal pain and disorders. The aim of this study was to quantify the postural demand, workload, and discomfort experienced by vascular surgeons and to identify procedural factors that influence surgical workload. Both objective (wearable posture sensors) and subjective (surveys) assessment tools were used to evaluate intraoperative workload during 47 vascular surgery procedures. Results demonstrate unfavorable neck and low back postures as well as high pain scores for those body segments. Additionally, workload from subjective surveys increased significantly as a function of operative duration, and mental workload was high across all procedure types. Neck postural risk exposure and physical demand were among the variables that increased with surgical duration, procedure type, and loupes used by the surgeons. Correlations among postural angles and pain scores showed consistency between the objective assessment and the subjective surveys for neck and trunk. The authors believe that the results of this study highlight the need for developing mitigating measures such as ergonomic interventions for vascular surgery.

Intraprocedural ergonomics of vascular surgeons.

OBJECTIVE: The objective of this study was to estimate the ergonomic postural risk (EPR) for musculoskeletal posture of vascular surgeons performing open and endovascular procedure types and with various adjunctive equipment using wearable inertial measurement unit (IMU) sensors. The hypothesis was that EPR will increase with increased physical and mental demand as well as with procedural complexity. METHODS: A prospective, observational study was conducted at a large, quaternary academic hospital located at two sites. Sixteen vascular surgeons (13 male) participated in the study. Participants completed a presurgery and postsurgery survey consisting of a body part discomfort scale and a modified NASA-Task Load Index. Participants wore IMU sensors on the head and upper body to measure EPR during open and endovascular procedures. RESULTS: Vascular surgeons have increased EPR scores of the neck as measured by the IMUs and increased lower back pain when performing open surgery compared with non-open surgery (P < .05). Open procedures were rated as more physically demanding. The use of loupes resulted in increased EPR scores for the neck and torso (P < .05), and they were significantly associated with higher levels of lower back pain during procedures (P < .05) as well as with higher levels of physical demand (P < .05). The use of headlights also resulted in increased subjectively measured levels of physical demand and lower back pain. In comparing survey responses with IMU data, surveyed physical demand was strongly and significantly correlated with the neck (r = 0.61; P < .0001) and torso (r = 0.59; P < .0001) EPR scores. The use of lead aprons did not affect EPR or most surveyed measures of workload but resulted in significantly higher levels of distraction (P < .01). The data presented highlight the potential of using wearable sensors to measure the EPR of surgeons during vascular surgical procedures. CONCLUSIONS: Vascular surgeons should be aware of EPR during the performance of their duties. Procedure type and surgical adjuncts can alter EPR significantly.

Intraoperative musculoskeletal discomfort and risk for surgeons during open and laparoscopic surgery.

BACKGROUND: Surgeon workload is significant both mentally and physically and may differ by procedure type. When comparing laparoscopic surgery and open surgery, studies have reported contrasting results on the physical and mental workload assessed. METHODS: Wearable posture sensors and pre-/post-surgical questionnaires were employed to assess intraoperative workload and to identify risk factors for surgeons using objective and subjective measures. RESULTS: Data from 49 cases (27 open and 22 laparoscopic surgeries performed by 13 male and 11 female surgeons) were assessed. More than half the surgeons reported a clinically relevant post-surgical fatigue score. The surgeons also self-reported a significant increase in pain for the neck, upper back, and lower back during/after surgery. Procedural time had significant impacts on fatigue, body part pain, and subjective (NASA-TLX) workload. The objectively assessed intraoperative work postures using wearable sensors showed a high musculoskeletal risk for neck and lower back based on their posture overall. Open surgeries had significantly larger neck angles (median [IQR]: 40 [28-47]°) compared with laparoscopic surgeries (median [IQR]: 23 [16-29]°), p < 0.001) and torso (median [IQR]: 17 [14-22]° vs. 13 [10-17]°, p = 0.006). CONCLUSION: Surgeons reported significantly higher levels of fatigue and pain in the neck and lower back during or after performing a surgical case. Longer procedural time resulted in more self-rated fatigue, pain, and subjective workload. Open surgery had higher postural risk. Overall, surgeons spent a disturbingly high percentage of time during surgery in high-risk musculoskeletal postures, especially the neck. These results show that intraoperative postural risk is very high and that interventions are necessary to protect surgeon musculoskeletal health for optimal surgeon performance and career longevity.

Ergonomic Robotic Console Configuration in Gynecologic Surgery: An Interventional Study.

STUDY OBJECTIVE: The objectives of this study were to (1) pilot a robotic console configuration methodology to optimize ergonomic posture, and (2) determine the effect of this intervention on surgeon posture and musculoskeletal discomfort. DESIGN: This was an institutional review board-approved prospective cohort study conducted from February 2017 to October 2017. SETTING: A single tertiary care midwestern academic medical center. PARTICIPANTS: Six fellowship-trained gynecologic surgeons, proficient in robotic hysterectomy, were recruited: 3 men and 3 women. INTERVENTIONS: Each surgeon performed 3 robotic hysterectomies using their self-selected robotic console settings (preintervention). Then, a robotic console ergonomic intervention protocol was implemented by trained ergonomists to improve posture and decrease time in poor ergonomic positions. Each surgeon then performed 3 robotic hysterectomies using the ergonomic intervention settings (postintervention). All surgeries used the da Vinci Xi surgical system (Intuitive Surgical, Inc., Sunnyvale, CA) and were the first case of the day. The surgeons wore inertial measurement unit (IMU) sensors on their head, chest, and bilateral upper arms during surgery. The IMU sensors are equipped with accelerometers, gyroscopes, and magnetometers to give objective measurements of body posture. IMU data were then analyzed to determine the percentage of time spent in ergonomically risky postures as categorized using a modified rapid upper limb assessment. Before and after each hysterectomy, the surgeons completed identical questionnaires for an assessment of musculoskeletal pain/discomfort. The outcome measurements were compared pre- versus postintervention on the basis of fitting generalized linear mixed models that handled the individual surgeon as a random effect and "setting" as a fixed effect. MEASUREMENTS AND MAIN RESULTS: With regard to the IMU posture results, there was a significant decrease in time spent in the moderate- to high-risk neck position and a decrease in average neck angle after the ergonomic intervention. The average percentage of time spent in moderate- to high-risk categories was significantly lower for the neck (mean, 54.3% vs 21.0%; p = .008) and right upper arm (mean, 15.5% vs 0.9%; p = .02) when using the intervention settings compared with the surgeons' settings. Pain score results: There were fewer reported increases in neck (4 [22%] vs 1 [6%]) and right shoulder (4 [22%] vs 2 [11%]) pain or discomfort after completion of robotic hysterectomy postintervention versus preintervention; however, these differences did not attain statistical significance (p = .12 and p = .37, respectively). CONCLUSION: An ergonomic robotic console intervention demonstrated effectiveness and improved objective surgeon posture at the console when compared with the surgeons' self-selected settings.

Accelerometry evaluation of shoulder movement and its association with patient-reported and clinical outcomes following reverse total shoulder arthroplasty.

BACKGROUND: Accelerometers provide a new method to objectively measure recovery of movement and physical activity in patients following reverse total shoulder arthroplasty (RTSA) and may overcome common limitations associated with patient-reported outcome measures (PROMs). The aim of this study was to assess changes in upper limb movement using accelerometers following RTSA and investigate their association with other clinical outcome measures. METHODS: Thirty-six patients who underwent RTSA wore accelerometers on both wrists and arms for 3 days at 3, 6, and 12 months postsurgery. PROMs (Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, visual analog scale for pain, Single Assessment Numerical Evaluation, Shoulder Activity Level) and isometric shoulder strength were also assessed. Accelerometer outcomes were calculated to quantify counts of forearm and arm activity and the contribution of both arms to activity (limb symmetry and magnitude ratio). Changes and differences in all clinical measures and objective movement measures were evaluated with within-subjects analysis of variance. Correlations between limb activity and other clinical measures were investigated using Spearman correlation coefficients. RESULTS: Objective movement of the operated arm increased from 3-6 months postsurgery (P = .004), but not from 6-12 months (P = .240). Limb asymmetries were observed at 3 and 6 months and improved by 12 months postsurgery. No associations were demonstrated between PROMs and objective upper limb movement at 12 months postsurgery. DISCUSSION: Despite early recovery of function and pain relief assessed by PROMs, objective movement using accelerometers showed delayed recovery of the operated arm postoperatively, before normalizing by 12 months postsurgery. Accelerometers provide a unique insight into functional recovery following RTSA.

Impact of Procedure Type, Case Duration, and Adjunctive Equipment on Surgeon Intraoperative Musculoskeletal Discomfort.

BACKGROUND: Surgeons are at high risk of developing musculoskeletal disorders. STUDY DESIGN: This study was designed to identify risk factors and assess intraoperative physical stressors using subjective and objective measures, including type of procedure and equipment used. Wearable sensors and pre- and postoperation surveys were analyzed. RESULTS: Data from 116 cases (34 male and 19 female surgeons) were collected across surgical specialties. Surgeons reported increased pain in the neck, upper, and lower back both during and after operations. High-stress intraoperative postures were also revealed by the real-time measurement in the neck and back. Surgical duration also impacted physical pain and fatigue. Open procedures had more stressful physical postures than laparoscopic procedures. Loupe usage negatively impacted neck postures. CONCLUSIONS: This study highlights the fact that musculoskeletal disorders are common in surgeons and characterizes surgeons' intraoperative posture as well as surgeon pain and fatigue across specialties. Defining intraoperative ergonomic risk factors is of paramount importance to protect the well-being of the surgical workforce.

Sitting versus standing makes a difference in musculoskeletal discomfort and postural load for surgeons performing vaginal surgery.

INTRODUCTION AND HYPOTHESIS: We compared musculoskeletal discomfort and postural load among surgeons in sitting and standing positions during vaginal surgery. MATERIALS AND METHODS: Assessment of discomfort and posture of the primary surgeons in both positions was performed at two institutions. The primary outcome was an increase in body discomfort score after surgery as determined from subjective responses using validated tools. The secondary outcome was the percentage of time spent in awkward body postures measured objectively and stratified into awkward postures for neck, trunk, and bilateral shoulder angles. Variables were compared between sitting and standing positions using Fisher's exact test for primary outcomes and Wilcoxon rank-sum test for secondary outcomes. RESULTS: Data were collected for 24 surgeries from four surgeons in sitting position and nine surgeries from nine surgeons in standing position. The standing surgeons reported a significant increase in discomfort postoperatively for bilateral wrists, thighs, and lower legs compared with the sitting surgeons. The median percentage of time spent in awkward postures was significantly lower for the trunk in the standing versus sitting position (median 0.3% vs 58.8%, p < 0.001) but was significantly higher for both shoulders in the standing versus the sitting position (right shoulder: median 17.8% vs 0.3%, p = 0.003; left shoulder: median 7.4% vs 0.2%, p = 0.003). CONCLUSION: Surgeons reported more discomfort in when performing vaginal surgery while standing. The postural load was worse for trunk but favorable for bilateral shoulders when seated. Such differences may impact a surgeon's decision to perform vaginal surgery seated rather than standing.

Patient-Reported and Objectively Measured Function Before and After Reverse Shoulder Arthroplasty.

BACKGROUND AND PURPOSE: Documenting functional outcomes after reverse shoulder arthroplasty (RSA) is critical to advancing patient care. The interplay been self-reported and objectively measured outcome measures has not been widely described. The utilization of wearable devices to document upper extremity limb activity is a new approach for objectively measuring outcomes. Therefore, the purpose of this study was to evaluate changes in pain, and self-reported function and objectively measured limb activity after RSA. We also assessed the influence of pain on self-reported function and objectively measured limb activity to determine the impact of pain on outcomes after RSA. MATERIALS: This study implemented a prospective, repeated-measures design. Fourteen patients undergoing RSA underwent testing before surgery, and 2 and 12 months after surgery. Patient-reported instruments included pain, Disabilities of Arm, Shoulder and hands (DASH), and physical component summary (PCS) of the 36-Item Short Form Health Survey. Objective limb activity (mean activity value, m/s/min epoch; inactive time, %; low activity, %; and high activity, %) was captured with triaxial accelerometers worn on the upper and lower arm. A repeated-measures ANOVA tested for differences across time. The Spearman rank-order correlation was calculated to evaluate the influence of pain on DASH, PCS scores, and mean limb activity. RESULTS: Patient-reported measures improved after surgery (pain, P < .01; DASH, P < .01; PCS, P = .01). No change in limb activity was found at 1 year compared with preoperative values for mean (forearm, P = 1.00; arm, P = .36), inactivity (forearm, P = .33; arm, P = .22), low (forearm, P = .77; arm, P = .11) or high (forearm, P = 1.00; arm, P = .20) activity. There was a relationship between pain and DASH scores 1 year after surgery (P = .04) but not before surgery (P = .16), or 2 months after surgery (P = .30). There was no relationship between pain and PCS scores at any time point (preoperative, P = .97; 2 months, P = .21; 1 year, P = .08) nor pain and limb activity (forearm: preoperative, P = .36; 2 months, P = .67; 1 year, P = .16; arm: preoperative, P = .97; 2 months, P = .59; 1 year, P = .51). CONCLUSIONS: RSA reduced pain and enhanced patient-perceived function. Objectively measured upper extremity limb activity is not different 1 year after surgery compared with preoperative levels. LEVEL OF EVIDENCE: III.

Kinematic and ergonomic assessment of laparoendoscopic single-site surgical instruments during simulator training tasks.

While laparoendoscopic single-site surgery (LESS) appears to be feasible and safe, instrument triangulation, tissue handling, and other bimanual tasks are difficult even for experienced surgeons. Novel technologies emerged to overcome LESS' procedural and ergonomic difficulties of "tunnel vision" and "instrument clashing." Surgeon kinematics, self-reported workload and upper body discomfort were used to compare straight, bent and two articulating instruments while performing two basic surgical tasks in a LESS simulator. All instruments resulted in bilateral elevation and rotation of the shoulders, excessive forearm motion and flexion and ulnar deviation of wrists. Surgeons' adopted non-neutral upper extremity postures and performed excessive joint excursions to compensate for reduced freedom of movement at the single insertion site and to operate the instrument mechanisms. LESS' cosmetic benefits continue to impact laparoscopic surgery and by enabling performance through improved instruments, ergonomic improvement for LESS can reduce negative impact on surgeon well-being and patient safety.

Technical Note: Development of a combined molecular breast imaging/ultrasound system for diagnostic evaluation of MBI-detected lesions.

PURPOSE: The purpose of this study was to perform a pilot evaluation of an integrated molecular breast imaging/ultrasound (MBI/US) system designed to enable, in real-time, the registration of US to MBI and diagnostic evaluation of breast lesions detected on MBI. METHODS: The MBI/US system was constructed by modifying an existing dual-head cadmium zinc telluride (CZT)-based MBI gamma camera. The upper MBI detector head was replaced with a mesh panel, which allowed an ultrasound probe to access the breast. An optical tracking system was used to monitor the location of the ultrasound transducer, referenced to the MBI detector. The lesion depth at which ultrasound was targeted was estimated from analysis of previously acquired dual-head MBI datasets. A software tool was developed to project the US field of view onto the current MBI image. Correlation of lesion location between both modalities with real-time MBI/US scanning was confirmed in a breast phantom model and assessed in 12 patients with a breast lesion detected on MBI. RESULTS: Combined MBI/US scanning allowed for registration of lesions detected on US and MBI as validated in phantom experiments. In patient studies, successful registration was achieved in 8 of 12 (67%) patients, with complete registration achieved in seven and partial registration achieved in one patient. In 4 of 12 (37%) patients, lesion registration was not achieved, partially attributed to uncertainty in lesion depth estimates from MBI. CONCLUSION: The MBI/US system enabled successful registration of US to MBI in over half of patients studied in this pilot evaluation. Future studies are needed to determine if real-time, registered US imaging of MBI-detected lesions may obviate the need to proceed to more expensive procedures such as contrast-enhanced breast MRI for diagnostic workup or biopsy of MBI findings.

Comparison of Tc-99m maraciclatide and Tc-99m sestamibi molecular breast imaging in patients with suspected breast cancer.

BACKGROUND: Molecular breast imaging (MBI) performed with 99mTc sestamibi has been shown to be a valuable technique for the detection of breast cancer. Alternative radiotracers such as 99mTc maraciclatide may offer improved uptake in breast lesions. The purpose of this study was to compare relative performance of 99mTc sestamibi and 99mTc maraciclatide in patients with suspected breast cancer, using a high-resolution dedicated gamma camera for MBI. Women with breast lesions suspicious for malignancy were recruited to undergo two MBI examinations-one with 99mTc sestamibi and one with 99mTc maraciclatide. A radiologist interpreted MBI studies in a randomized, blinded fashion to assign an assessment score (1-5) and measured lesion size. Lesion-to-background (L/B) ratio was measured with region-of-interest analysis. RESULTS: Among 39 analyzable patients, 21 malignant tumors were identified in 21 patients. Eighteen of 21 tumors (86%) were seen on 99mTc sestamibi MBI and 19 of 21 (90%) were seen on 99mTc maraciclatide MBI (p = 1). Tumor extent measured with both radiopharmaceuticals correlated strongly with pathologic size (99mTc sestamibi, r = 0.84; 99mTc maraciclatide, r = 0.81). The L/B ratio in detected breast cancers was similar for the two radiopharmaceuticals: 1.55 ± 0.36 (mean ± S.D.) for 99mTc sestamibi and 1.62 ± 0.37 (mean ± S.D.) for 99mTc maraciclatide (p = 0.53). No correlation was found between the L/B ratio and molecular subtype for 99mTc sestamibi (r s = 0.12, p = 0.63) or 99mTc maraciclatide (r s = -0.12, p = 0.64). Of 20 benign lesions, 10 (50%) were seen on 99mTc sestamibi and 9 of 20 (45%) were seen on 99mTc maraciclatide images (p = 0.1). The average L/B ratio for benign lesions was 1.34 ±0.40 (mean ±S.D.) for 99mTc sestamibi and 1.41 ±0.52 (mean ±S.D.) for 99mTc maraciclatide (p = 0.75). Overall diagnostic performance was similar for both radiopharmaceuticals. AUC from ROC analysis was 0.83 for 99mTc sestamibi and 0.87 for 99mTc maraciclatide (p = 0.64). CONCLUSIONS: 99mTc maraciclatide offered comparable lesion uptake to 99mTc sestamibi, in both malignant and benign lesions. There was good correlation between lesion extent and uptake measured from both radiopharmaceuticals. 99mTc maraciclatide offered a marginal (but not significant) improvement in sensitivity over 99mTc sestamibi. Our findings did not support an association between the uptake of either radiopharmaceutical and tumor molecular subtype. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00888589.

Validation of Inertial Measurement Units for Upper Body Kinematics.

The purpose of this study was to validate a commercially available inertial measurement unit (IMU) system against a standard lab-based motion capture system for the measurement of shoulder elevation, elbow flexion, trunk flexion/extension, and neck flexion/extension kinematics. The validation analyses were applied to 6 surgical faculty members performing a standard, simulated surgical training task that mimics minimally invasive surgery. Three-dimensional joint kinematics were simultaneously recorded by an optical motion capture system and an IMU system with 6 sensors placed on the head, chest, and bilateral upper and lower arms. The sensor-to-segment axes alignment was accomplished manually. The IMU neck and trunk IMU flexion/extension angles were accurate to within 2.9 ± 0.9 degrees and 1.6 ± 1.1°, respectively. The IMU shoulder elevation measure was accurate to within 6.8 ± 2.7° and the elbow flexion measure was accurate to within 8.2 ± 2.8°. In the Bland-Altman analyses, there were no significant systematic errors present; however, there was a significant inversely proportional error across all joints. As the gold standard measurement increased, the IMU underestimated the magnitude of the joint angle. This study reports acceptable accuracy of a commercially available IMU system; however, results should be interpreted as protocol specific.

Intraoperative workload in robotic surgery assessed by wearable motion tracking sensors and questionnaires.

BACKGROUND: The introduction of robotic technology has revolutionized radical prostatectomy surgery. However, the potential benefits of robotic techniques may have trade-offs in increased mental demand for the surgeon and the physical demand for the assisting surgeon. This study employed an innovative motion tracking tool along with validated workload questionnaire to assess the ergonomics and workload for both assisting and console surgeons intraoperatively. METHODS: Fifteen RARP cases were collected in this study. Cases were performed by 10 different participants, six primarily performed console tasks and four primarily performed assisting tasks. Participants had a median 12 (min-3, max-25) years of surgical experience. Both console and assisting surgeons performed robotic prostatectomy cases while wearing inertial measurement units (IMUs) that continuously track neck, shoulder, and torso motion without interfering with the sterile environment. Postoperatively, participants completed a workload questionnaire (SURG-TLX) and a body part discomfort questionnaire. RESULTS: Twenty-six questionnaires were completed from 13 assisting and 13 console surgeons over the 15 cases. Postoperative pain was reported highest for the right shoulder and neck. Mental demands were 41 % higher for surgeons at the console than assisting (p < 0.05), while physical demands were not significantly different. Assisting surgeons worked in demanding neck postures for 58 % of the procedure compared to 24 % for the console surgeon (p < 0.01). Surgeons at the console were primarily static and showed 2-5 times fewer movements than assisting surgeons (p < 0.01). CONCLUSIONS: Postures were more ergonomic during console tasks than when assisting by the bedside; however, the console may constrain postures leading to static loads that have been associated with musculoskeletal symptoms for the neck, torso, and shoulders. The IMU sensors were effective at quantifying ergonomics in robotic prostatectomies, and these methods and findings have broad applications to other robotic procedures.

Effect of chair types on work-related musculoskeletal discomfort during vaginal surgery.

BACKGROUND: Evidence supports that surgeons are at high risk for work-related musculoskeletal disorders. OBJECTIVE: The objective of the study was to compare the effect of different chairs on work-related musculoskeletal discomfort for surgeons during vaginal operations. STUDY DESIGN: This crossover study randomly assigned 4 surgeons to 4 chair types using a 4 × 4 Latin square model: a conventional round stool, a round stool with a backrest, a saddle chair with a backrest, and a Capisco chair. Subjective assessments of surgeon discomfort were performed with a validated body discomfort survey, and workload was assessed with the surgical task load index. The objective postural load was quantified with inertial measurement units of the modified rapid upper limb assessment limits. Subjective and objective assessments of chair comfort were performed with an 11 point scale and seat interface pressure-mapped distributions, respectively. The primary outcome was the difference in body discomfort scores between pre- and postsurgery measurements. Secondary outcomes were the differences in chair comfort scores, postural load, and seating interface pressure-mapped distribution. For each outcome, comparisons among the chair types were based on fitting a linear mixed model that handled the surgeon as a random effect and the chair type as a fixed effect. RESULTS: Data were collected for 48 vaginal procedures performed for pelvic organ prolapse. Mean (SD) duration of surgery was 122.3 (25.1) minutes. Surgeons reported body discomfort during 31 procedures (67.4%). Subjective increase in discomfort from the preoperative state was noted most commonly in the lower back (n = 14, 30.4%), followed by right shoulder (n = 12, 26.1%), upper back (n = 8, 17.4%), hips and buttocks (n = 7, 15.2%), left shoulder (n = 6, 13.0%), right or left thigh (n = 6, 13.0%), and neck (n = 6, 13.0%). Pre- and postsurgery body discomfort scores did not differ with respect to chair type. Chair discomfort scores for the round stool and the saddle chair were significantly higher than the round stool with backrest and the Capisco chair (P < .001). Although the average modified rapid upper limb assessment postural scores showed moderate to high musculoskeletal risk of neck and shoulder discomfort across the 4 surgeons; chair type did not affect postural scores. The saddle chair had significantly reduced dispersion of seated pressure vs the round stool with backrest (P ≤ .001), depicted by the number of cells with pressure values >5 mm Hg. An increased dispersion of pressure across the chair surface was associated with increased comfort (Spearman correlation, 0.40, P = .006). CONCLUSION: Musculoskeletal strain and associated discomfort for surgeons are very high during vaginal operations. Chair type can affect comfort, and chairs with more uniform distribution and fewer pressure points are more comfortable. However, the chair type used in surgery did not influence the musculoskeletal postural load findings.

Novel approaches to objectively assess shoulder function.

BACKGROUND: The purpose of this study was to evaluate the effectiveness of existing technologies implemented in a novel manner to objectively capture upper extremity function. MATERIALS AND METHODS: Patients scheduled to undergo reverse shoulder arthroplasty were recruited for the study. Functional limb use was measured with triaxial accelerometers worn in the subjects' natural living environment. Functional reach area was captured by 3-dimensional motion analysis testing as subjects were asked to circumduct their limb, reaching as far as possible in a circular manner. Statistical testing (α ≤ .05) was performed by paired t tests to identify differences between limbs. RESULTS: There was no difference in functional limb activity between sides for the lower (P = .497) or upper arm (P = .918) for inactivity time. Mean activity was greater for the uninvolved limb compared with the involved limb (lower arm, P = .045; upper arm, P = .005). Low-intensity activity was greater for the involved arm compared with the uninvolved arm (lower arm, P = .007; upper arm, P = .015), whereas high-intensity activity was greater for the uninvolved arm (lower arm, P = .013; upper arm, P = .005). Radius of the functional reach area was greater for the uninvolved limb compared with the involved limb (P = .006). CONCLUSIONS: Novel methods of capturing function were effective in discerning differences in side-to-side abilities among patients scheduled to undergo reverse shoulder arthroplasty. These testing procedures may be used to capture function across a spectrum of shoulder diseases. These objective data are invaluable in assessing the impact of disease and recovery after intervention and obtaining reimbursement from third-party payers.

Elevated postoperative blood glucose and preoperative hemoglobin A1C are associated with increased wound complications following total joint arthroplasty.

BACKGROUND: Diabetes is an established risk factor for complications following total joint arthroplasty. However, the correlation between postoperative blood glucose and preoperative hemoglobin A1C levels with complications following total joint arthroplasty is not well described. METHODS: All patients undergoing elective primary total joint arthroplasty at our institution from 2004 through 2011 with both postoperative blood glucose and preoperative hemoglobin A1C levels were identified in a retrospective review. From among 1702 patients, those with wound complications within thirty days after the index arthroplasty were identified. A control group matched for exact age, sex, procedure, tourniquet use, surgical approach, and use of antibiotic cement was also created. Thirty patients met the study group inclusion criteria. The mean patient age was seventy-two years (range, fifty-three to eighty-nine years); the majority (53%) of patients were female. RESULTS: The odds ratio for developing a wound complication was 3.75 (95% confidence interval, 1.25 to 11.22; p = 0.02) in patients with a mean postoperative glucose of >200 mg/dL, 3.0 (95% confidence interval, 0.97 to 9.30; p = 0.08) in patients with a maximum postoperative blood glucose of >260 mg/dL, and 9.0 (95% confidence interval, 1.14 to 71.20; p = 0.03) in patients with a preoperative hemoglobin A1C value of >6.7%. CONCLUSIONS: Patients with a mean postoperative blood glucose of >200 mg/dL or a preoperative hemoglobin A1C level of >6.7% are at increased risk for wound complications following elective primary total joint arthroplasty. These results show that poor preoperative and postoperative glucose control is independently associated with wound complications.