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Here, we describe a digital-waveform dual-quadrupole mass spectrometer that enhances the performance of our drift tube FT-IMS high-resolution Orbitrap mass spectrometer (MS). The dual-quadrupole analyzer enhances the instrument capabilities for studies of large protein and protein complexes. The first quadrupole (q) provides a means for performing low-energy collisional activation of ions to reduce or eliminate noncovalent adducts, viz., salts, buffers, detergents, and/or endogenous ligands. The second quadrupole (Q) is used to mass-select ions of interest for further interrogation by ion mobility spectrometry and/or collision-induced dissociation (CID). Q is operated using digital-waveform technology (DWT) to improve the mass selection compared to that achieved using traditional sinusoidal waveforms at floated DC potentials (>500 V DC). DWT allows for increased precision of the waveform for a fraction of the cost of conventional RF drivers and with readily programmable operation and precision (Hoffman, N. M. . A comparison-based digital-waveform generator for high-resolution duty cycle. Review of Scientific Instruments 2018, 89, 084101).

Waveform reproducibility is a critical factor for performing high resolution mass analysis with digitally operated quadrupole mass filters and traps operating in higher stability zones. In this work, Hill equation-based stability calculations were used to define the effect of period jitter on mass analysis in higher stability zones. These calculations correlate well with experimental observations in higher stability zones. Comparison of experiment to theory supplies the basis for defining jitter-based expectations and limits for mass analysis in higher zones.

Mass filter operation in higher stability zones is known to provide better resolution. Unfortunately, for sine driven instruments, higher stability zone operation reduces the accessible mass range and increases the degenerative effects of fringe fields. Conversely, digitally driven mass filters do not suffer from loss of mass range, and the fringe field effects do not increase significantly by switching stability zones because the AC voltage is always constant and the DC voltage is always zero. This work catalogues 12 stability zones that are accessible with the new digital waveform generation technology. These zones have theoretical baseline resolving powers that range from 22 to 1 300 000 with pseudopotential well depths that range from 3.5 to 43 V. Operation in higher stability zones also has the advantage of aligned axial stability wells. That alignment maximizes the pseudopotential well depth for each higher stability zone, making them more than an order of magnitude greater than the standard ∼0.2 V well of a sine filter operating in the first stability zone at unit resolution. Increased pseudopotential well depth correlates with better ion transmission and sensitivity. Our theoretical examination suggests that the digital mass filter can obtain both high resolution and high sensitivity with essentially unlimited mass range.

Aims The purpose of this study was to evaluate the cost of reverse shoulder arthroplasty (RSA) for patients with a proximal humerus fracture, using time-driven activity based costing (TDABC), and to compare treatment costs with reimbursement under the Healthcare Resource Groups (HRGs). Methods TDABC analysis based on the principles outlined by Kaplan and a clinical pathway that has previously been validated for this institution was used. Staffing cost, consumables, implants, and overheads were updated to reflect 2019/2020 costs. This was compared with the HRG reimbursements. Results The mean cost of a RSA is £7,007.46 (£6,130.67 to £8,824.67). Implants and staffing costs were the primary cost drivers, with implants (£2,824.80) making up 40% of the costs. Staffing costs made up £1,367.78 (19%) of overall costs. The total tariff, accounting for market force factors and high comorbidities, reimburses £4,629. If maximum cost and minimum reimbursement is applied the losses to the trust are £4,828.67. Conclusion RSA may be an effective and appropriate surgical option in the treatment of proximal humerus fractures; however, a cost analysis at our centre has demonstrated the financial burden of this surgery. Given its increasing use in trauma, there is a need to work towards generating an HRG that adequately reimburses providers. Cite this article: Bone Jt Open 2020;1-12:731–736.

International audience; BackgroundThe critical shoulder angle (CSA) has been shown to be correlated with shoulder disease states. The biomechanical hypothesis to explain this correlation is that the CSA changes the shear and compressive forces on the shoulder. The objective of this study is to test this hypothesis by use of a validated computational shoulder model. Specifically, this study assesses the impact on glenohumeral biomechanics of modifying the CSA.MethodsAn inverse dynamics 3-dimensional musculoskeletal model of the shoulder was used to quantify muscle forces and glenohumeral joint forces. The CSA was changed by altering the attachment point of the middle deltoid into a normal CSA (33°), a reduced CSA of 28°, and an increased CSA of 38°. Subject-specific kinematics of slow and fast speed abduction in the scapular plane and slow and fast forward flexion measured by a 3-dimensional motion capture system were used to quantify joint reaction shear and compressive forces.ResultsIncreasing the CSA results in increased superior-inferior forces (shearing forces; integrated over the range of motion; P < .05). Reducing CSA results in increased lateromedial (compressive) forces for both the maximum and integrated sum of the forces over the whole motion (P < .01).Discussion/ConclusionChanges in the CSA modify glenohumeral joint biomechanics with increasing CSA producing higher shear forces that could contribute to rotator cuff overuse, whereas reducing the CSA results in higher compressive forces that contribute to joint wear.

Here, we describe a digital-waveform dual-quadrupole mass spectrometer that enhances the performance of our drift tube FT-IMS high-resolution Orbitrap mass spectrometer (MS). The dual-quadrupole analyzer enhances the instrument capabilities for studies of large protein and protein complexes. The first quadrupole (q) provides a means for performing low-energy collisional activation of ions to reduce or eliminate noncovalent adducts, viz., salts, buffers, detergents, and/or endogenous ligands. The second quadrupole (Q) is used to mass-select ions of interest for further interrogation by ion mobility spectrometry and/or collision-induced dissociation (CID). Q is operated using digital-waveform technology (DWT) to improve the mass selection compared to that achieved using traditional sinusoidal waveforms at floated DC potentials (>500 V DC). DWT allows for increased precision of the waveform for a fraction of the cost of conventional RF drivers and with readily programmable operation and precision (Hoffman, N. M. et al.. A comparison-based digital-waveform generator for high-resolution duty cycle.

Mass analysis in a linear ion trap is traditionally performed using resonant ejection induced by auxiliary waveforms. For sinusoidally driven ion traps without resonant ejection, resolution and sensitivity are poor because mass-selected instability yields excitation along both the x and y axes simultaneously. Digital ion traps, on the other hand, have the advantage of duty cycle manipulation that can be used to change the ion excitation along the x and y axes. Consequently, the duty cycle can be used to enhance the resolution and sensitivity for mass-selected instability in a linear ion trap without the application of an auxiliary waveform. This work introduces and explores mass-selected instability in a linear trap without the use of auxiliary waveforms.

A quadrupoles acceptance is a measure of its ability to catch ions with certain trajectories. One way to calculate acceptance is the method of ellipses. The method arose partly from a simplification that trajectories could be calculated for an electrode axis independently of others. It has been used to calculate the acceptance and transmission of sine-driven quadrupole mass filters for over 50 years. Although the method is straightforward, it is generally described with little detail or presented as a confusing string of equations. As such, it may not be decipherable by all practitioners. For this reason, the first half of this paper presents a practical explanation of the method of ellipses and the concepts that make it work. Only equations necessary to describe the method are introduced. The tutorial also prepares the reader for the second half, which presents an alternative approach for calculating acceptance based on an array of initial trajectories. The alternative approach is used to compare the acceptance of simplified sinusoidal and digital ion guides. The method of ellipses was applied to validate results of the new approach for calculation of acceptance.

Digital waveform technology allows the waveform frequency and duty cycle to be instantly changed. These sudden changes affect ion motion and hence ion energy. Mass spectrometrists can take advantage of these sudden changes to isolate or excite trapped ions. To understand these processes on the microsecond time scale, a theoretical treatment of ion motion during the first repetitions of the newly applied waveform is needed. Fortunately, the matrix solution to the Hill equation allows the observation of ion trajectories before, during, and after the waveform transition process. This study begins the investigation of the short time scale effects of changing waveforms on ion motion.

A quarter of patients admitted with a proximal femoral fracture suffer from an acute episode of delirium during their hospital stay. Yet it is often unrecognised, poorly managed, and rarely discussed by doctors. Delirium is important not only to the affected individuals and their families, but also socioeconomically to the broader community. Delirium increases mortality and morbidity, leads to lasting cognitive and functional decline, and increases both length of stay and dependence on discharge. Delirium should be routinely and openly discussed by all members of the clinical team, including surgeons when gaining consent. Failing to do so may expose surgeons to claims of negligence. Here we present a concise review of the literature and discuss the epidemiology, causative factors, potential consequences and preventative strategies in the perioperative period.

Background: The effects of weather on overall mortality are well documented. Anecdotally, icy conditions are perceived to result in more falls and admissions for neck of femur (NOF) fractures. The aim of this pilot study was to determine whether relationships could be extracted or at least not ruled out by analysing a small dataset, and so give impetus to a larger project. Methods: Seven trauma units across North West London were identified and NOF fracture data extracted for 5 years. Visual inspection of the time series, consideration of the weather on specific days and correlation analysis were used to assess associations between fracture numbers and a variety of weather parameters (temperature, rainfall, wind and ice risk). Results: Overall, 10929 individuals with hip fractures were admitted over the 5-year period. The highest number of admissions in a day was 14. No clear association was found between a weather parameter and daily admissions. However, when accumulated to a weekly timescale, a negative relationship with maximum temperature was found. No seasonal cycle was detected. Conclusion: The lack of a daily relationship and presence of a weekly relationship points to a possible delayed response to weather or insufficient daily data to extract a signal. The inconclusive results also indicate a larger data sample is required in future studies. In addition, even in cold weather an urban environment may not create icy conditions, being ameliorated by the heat island effect and gritting.

A tandem mass filter consists of two low-resolution mass filters arranged in series that operate with a small offset between their mass windows. In principle, the overlap of the two individual mass windows defines the tandem window. Tandem operation provides improved resolution and transmission compared to a single mass filter operated with the same mass window. The improvement in transmission is owed to the larger acceptance of the low-resolution quadrupoles. The tandem filter resolution and transmission are adjusted by changing the amount of offset separating the mass windows of the individual filters. Sine wave systems create this offset through voltage changes. Digital tandem mass filters depart from convention because they do not change voltage. The tandem mass window is created when the individual filters are operated with two slightly different duty cycles. Both quadrupoles operate at the same frequency, phase, and voltage. When the frequency, phase, and voltage of each quadrupole are identical, there theoretically are no changes to the Mathieu parameters to cause ion excitation and loss during transition between the quadrupole pair. The work presented here shows that a fixed AC voltage digital tandem mass filter can only operate in higher stability zones. However, unlike sine mass filters, the mass range of a digital system is not limited. This makes the digital tandem mass filter feasible as a commercial product. For the tandem digital mode to be successful, the duty cycles of each quadrupole must be precisely controlled because the duty cycle differences required to shift the mass windows are small. The creation of these mass window offsets requires waveform generation that can obtain high duty cycle resolution. Our method of generating waveforms can meet this demand; however, modifications to our current printed circuit board must be made. These modifications are minor and will be discussed.

Even though sinusoidal quadrupole mass filters have been around for more than 50 years, the relationships defining resolution, resolving power, and transmission from the applied voltages have not been rigorously quantified or discussed. Traditional quadrupole mass filter theory implies that voltages are scanned at constant direct current (DC) to alternating current (AC) voltage ratios with the scanline passing through the origin of the voltage stability diagram. A prominent feature of constant voltage ratio scans is constant baseline theoretical resolving power (m/Δm) that is the same for all masses. Commercial quadrupole instruments rarely scan at constant resolving power because ion transmission increases with mass. Instead, they scan at constant resolution, meaning that the mass window width is fixed. Constant resolution mass scans are preferred because ion transmission does not change with mass. Commercial mass filter systems create constant resolution scans by linearly changing the DC and AC voltages at a fixed ratio in the presence of an additional negative DC voltage offset. This manuscript systematically quantifies the effects of the DC and AC voltages on resolution, resolving power, pseudopotential well depth, and transmission. To quantify these properties, recently developed spreadsheet tools that calculate the laboratory frame stability of ions from the matrix solutions of Hill's equation were used. Voltage scanning methods and their effects on theoretically determined transmission and sensitivity will be discussed.

The Rockwood type VI acromioclavicular joint injury describes subcoracoid dislocation of the distal end of the clavicle. This injury pattern is exceedingly rare, with only 12 cases described in the literature. Diagnosis can be challenging; it is often the result of a high-energy mechanism and patients frequently have other severe distracting injuries. We report the case of a 23-year-old man who presented to our department after falling from a fifth-floor balcony. Alongside multiple intra-abdominal and musculoskeletal injuries, the patient sustained a type VI acromioclavicular joint dislocation. This injury was not picked up on the initial clinical assessment or described in the initial radiology report, with the diagnosis only made upon subsequent repeat review of the imaging by the admitting team. Fortunately, this delay did not increase the time to the patient receiving appropriate treatment. Despite its rarity, awareness of this injury pattern and its association with polytrauma is essential to reduce the risk of the diagnosis being overlooked in the acute setting.

Heavily loaded overhead training tasks, such as pull-ups are an effective strength training and rehabilitation exercise requiring high muscle forces maintained over a large range of motion. This study used experiments and computational modeling to examine loading patterns during three different pull-up variants and highlighted risks to vulnerable musculoskeletal structures. Optical motion tracking and a force platform captured kinematics and kinetics of 11 male subjects with no history of shoulder pathology, during performance of three pull-up variants-pronated front grip, pronated wide grip, and supinated reverse grip. UK National Shoulder model (UKNSM) simulated biomechanics of the shoulder girdle. Muscle forces and activation patterns were analyzed by repeated measures ANOVA with post-hoc comparisons. Motor group recruitment was similar across all pull-up techniques, with upper limb depression occurring secondary to torso elevation. Stress-time profiles show significant differences in individual muscle patterns among the three pull-up variants, with the most marked differences between wide grip and reverse grip. Comparing across techniques, latissimus dorsi was relatively more active in wide pull-ups (P < .01); front pull-ups favored activation of biceps brachii and brachialis (P < .02); reverse pull-ups displayed higher proportional rotator cuff activation (P < .01). Pull-ups promote stability of the shoulder girdle and activation of scapula stabilizers and performing pull-ups over their full range of motion is important as different techniques and phases emphasize different muscles. Shoulder rehabilitation and strength & conditioning programs should encourage incorporation of all three pull-up variants with systematic progression to provide greater global strengthening of the torso and upper limb musculature.

The first completely digital quadrupole mass filter was recently introduced. There is now a need to understand and demonstrate the benefits of digital operation and compare them to the commercial standards. Our work to date has demonstrated that sine and square wave operation are very similar because of their similar stability diagrams and because they use a direct current (DC) potential between the electrode pairs to narrow and limit the mass range. In contrast, rectangular wave-operated digital mass filters and ion traps narrow and limit the stable mass range with the waveform duty cycle without the need for a DC potential. To understand and compare the differences between rectangular and sinusoidal modes of operation, our group has developed new spreadsheet tools that permit calculation of the m/z versus frequency space stability diagrams with the application of a DC potential between the electrode sets for rectangular and sine waveforms, and plots of the pseudopotential well depth against the entire range of stable m/zs for rectangular and sine waveforms. Our spreadsheets were used to make comparisons between fixed-frequency variable-voltage and fixed-voltage variable-frequency modes of operation. They provide a comprehensive companion tool for operating in the laboratory frame and are tunable to the instrument. This manuscript introduces these tools as it compares sine and rectangular wave modes of operation and provides a basis for understanding the advantages and disadvantages of digital operation relative to conventional technology.

The prevention, mitigation and treatment of movement impairments, ideally, requires early diagnosis or identification. As the human movement system has physiological and functional redundancy, movement limitations do not promptly arise at the onset of physical decline. A such, prediction of movement limitations is complex: it is unclear how much decline can be tolerated before movement limitations start. Currently, the term ‘homeostatic reserve’ or ‘physiological reserve’ is used to refer to the redundancy of the human biological system, but these terms do not describe the redundancy in the muscle architecture of the human body. The result of functional redundancy is compensation. Although compensation is an early predictor of movement limitations, clear definitions are lacking and the topic is underexposed in literature. The aim of this article is to provide a definition of compensation and emphasize its importance. Compensation is defined as an alteration in the movement trajectory and/or altering muscle recruitment to complete a movement task. Compensation for capacity is the result of a lack in neuromusculoskeletal reserve, where reserve is defined as the difference between the capacity (physiological abilities of the neuromusculoskeletal system) and the task demand. Compensation for movement objectives is a result of a shift in weighting of movement objectives, reflecting changing priorities. Studying compensation in biomechanics requires altered protocols in experimental set-ups, musculoskeletal models that are not reliant on prescribed movement, and inclusion of alternative movement objectives in optimal control theory.

Aims Patients with recurrent anterior dislocation of the shoulder commonly have an anterior osseous defect of the glenoid. Once the defect reaches a critical size, stability may be restored by bone grafting. The critical size of this defect under non-physiological loading conditions has previously been identified as 20% of the length of the glenoid. As the stability of the shoulder is load-dependent, with higher joint forces leading to a loss of stability, the aim of this study was to determine the critical size of an osseous defect that leads to further anterior instability of the shoulder under physiological loading despite a Bankart repair. Patients and Methods Two finite element (FE) models were used to determine the risk of dislocation of the shoulder during 30 activities of daily living (ADLs) for the intact glenoid and after creating anterior osseous defects of increasing magnitudes. A Bankart repair was simulated for each size of defect, and the shoulder was tested under loading conditions that replicate in vivo forces during these ADLs. The critical size of a defect was defined as the smallest osseous defect that leads to dislocation. Results The FE models showed a high risk of dislocation during ADLs after a Bankart repair for anterior defects corresponding to 16% of the length of the glenoid. Conclusion This computational study suggests that bone grafting should be undertaken for an anterior osseous defect in the glenoid of more than 16% of its length rather than a solely soft-tissue procedure, in order to optimize stability by restoring the concavity of the glenoid.

Following open reduction and internal fixation for a proximal humerus fracture a 71-year-old man re-presented with wound changes consistent with infection and elevated inflammatory markers. No significant improvement was seen with concomitant intravenous antibiotics and multiple debridement procedures. This case was further complicated by soft tissue breakdown at the site of a left thigh haematoma also requiring debridement. Surgical site infections represent the most common cause of morbidity postoperatively. This case highlights the importance of considering a number of differential diagnoses. A diagnosis of pyoderma gangrenosum prompted systemic corticosteroid therapy giving rapid clinical improvement.

Digitally driven mass filter analysis is an advancing field. This work presents a tutorial of digital waveforms, stability diagrams, and pseudopotential well plots. Experimental results on digitally driven mass filter analysis in stability zones A and B are also shown. This work explains duty cycle manipulation of the waveforms to axially trap and eject ions from linear quadrupoles and how to change and distort the stability diagrams to create mass filters and their effects on the pseudopotential well depth. It discusses the sensitivity and resolution that can be obtained and what limits these benchmarks. It reveals the advantages of mass filter operation without any added direct current potential between the quadrupole electrodes (a = 0).

Digital Waveform Technology (DWT) has recently evolved to provide sufficient duty cycle resolution necessary to create a purely digital waveform-based mass filter. Digital operation provides a number of options that remain extremely challenging for sinusoidal waveform technology (SWT) driven systems. One of those options is collecting ions in a gas-filled digital ion guide/trap and subsequently axially injecting the collected ions in a temporally-short and spatially-focused packet into the digital mass filter (DMF). This work explores the effects of trapping ions before mass analysis. In particular, it focusses on the measured response of the ion distribution as a function of axial ejection conditions while maintaining identical trapping conditions. The ejection energy was varied showing changes in the ion distribution that corresponded to desolvation, multimeric dissociation and small molecule from the higher charge states. This study shows that duty cycle-base ion ejection from into an axial potential well and out of the same well of a gas-filled linear quadrupole is essentially equivalent in terms of energy imparted to the ion. However, the energizing mechanism of the ejection process is radial rather than axial. Sampling issues of the trapped ions from the gas-filled quadrupole were analyzed and discussed.

International audience; IntroductionOne hundred years ago, before Bankart, Latarjet or Bristow, Eden and Hybbinette developed a procedure to treat anterior shoulder instability and currently, this eponymous term is known by every shoulder surgeon. The purpose of this review is to summarise the historical “Eden-Hybbinette” procedure and its evolutions during the last century and discuss results.MethodOn the centenary of the first publication on the “Eden-Hybbinette procedure”, a search was conducted on Medline, Google Scholar and in the grey literature, to find its initial concept and description, and the evolutions.ResultsThe initial procedure was based on the concepts of glenoid bony augmentation (anatomic reconstruction with an autograft from the tibia) and capsulorrhaphy. The main evolutionary themes identified were the origin of the graft (autograft with iliac crest, allograft), graft positioning and fixation (no fixation device, screws), and the surgical approach (split of the subscapularis tendon in open surgery, arthroscopy). Studies with long-term follow-up exhibited good results, considered similar as those with other classic bone-block procedures. Development of osteoarthritis during the following years after the procedure is not usual and not related to the graft unless if there is articular protrusion.ConclusionThe Eden-Hybbinette procedure is one of the oldest surgical interventions still commonly used for chronic anterior shoulder instability. The changes to the procedure over the last 100 years allow it to remain a contemporary solution for both primary surgery and revision cases.

To prevent, mitigate and treat movement impairments, we need to recognize early signs of decline and understand how to best compensate for limitations. The mechanisms leading to movement impairments are complex, overlapping, and interdependent and the fields of biomechanics, motor control, and physiology must be combined to understand these mechanisms. This article introduces CaReMoOC, a framework incorporating neuromusculoskeletal capacity (accumulation of neuromusculoskeletal resources over the lifespan), reserve (task-specific difference between capacity and task demand), movement objectives (considerations made to plan a movement), and compensation (use of NMSK resources to respond to the task demand). The framework is demonstrated for healthy ageing, providing an overview of age-related capacity decline (neural, skeletal, muscular system) and shifted weighting of movement objectives (energy, pain, stability, speed) relevant for biomechanics and motor control. Two forms of compensation are Compensation for Capacity, when capacity does not meet the task demands, and Compensation for Movement Objectives, when the movement is changed due to for example a fear of falling. Understanding the interrelationships between decline in the variables within capacity and the effect on compensation strategies will provide benefit in preventing mobility impairments and will support clinicians in their rehabilitation practice.

In healthy ageing, capacity declines in the neural, muscular, and skeletal systems, and each system decline has its effect on the execution of complex motor tasks. This decline in capacity can result in the inability to stand up (sit-to-stand, sit-to-walk), which is a key movement for independence. The mechanisms leading to mobility limitations or inabilities are complex, overlapping, and interdependent and the complementary fields of biomechanics, motor control, and physiology need to be combined to understand these mechanisms. The aim of this review is to provide an overview of the current knowledge of age-related compensation in standing up and to consider the limitations of these results when analysing standing up in daily life using the Capacity, Reserve, Movement Objectives, and Compensation (CaReMoOC) framework that combines biomechanics, motor control, and physiology. A literature search was performed in the search engine Scopus, using the keywords and their synonyms: strateg*(approach, technique, way) AND, sit-to-walk OR sit-to-stand OR rise (raise, arise, stand, stand-up) AND chair (seat). Inclusion criteria were: biomechanics or motor control on sit-to-stand or sit-to-walk in healthy and/or frail adults (60y), and/or osteoarthritis patients as a specific case of ageing related decline. The review shows that movement compensations in standing up manifest as changes in planned trajectory (Compensation by Selection) and in muscle recruitment (Compensation by Reorganisation). However, as most studies in the literature typically use standardized experimental protocols where movement compensation is restricted, these studies cannot be directly translated to functional tasks, such as the mobility of the elderly in their homes, communities, and clinic. Compensation must be included in future studies in order to facilitate clinical translation. Specifically, future studies in the standing up task should 1) determine the effect of varying arm use strategies (e.g., armrests, knees, chair, cane) on trunk and both lower limb and upper limb joint loading, 2) analyse control strategies in elderly people, 3) determine the biomechanical implications of asymmetry, and 4) incorporate assessments of age-related physical and neural decline as well as changes in psychological priorities.

The accurate placement of orthopaedic implants according to a biomechanically derived preoperative plan is an important consideration in the long-term success of these interventions. Guidance technologies are widely described however, high cost, complex theatre integration, intraoperative inefficiency and functional limitations have prevented the widespread use. A novel, intraoperative mechatronics platform is presented, capable of the rapid, intraoperative manufacture of low-cost patient-specific guides. The device consists of a tableside robot with sterile drapes and some low cost, sterile disposable components. The robot comprises a 3D optical scanner, a three-axis sterile computer numerical control (CNC) drill and a two-axis receptacle into which the disposable consumables may be inserted. The sterile consumable comprises a region of rapidly setting moldable material and a clip allowing it to be reversibly attached to the tableside robot. In use, patient computed tomography (CT) imaging is obtained at any point prior to surgery and a surgical plan is created on associated software. This plan describes the axis and positioning of one or more guidewires which may, in turn, locate the prosthesis into position. Intraoperatively, osseous anatomy is exposed, and the sterile disposable is used to rapidly create a mould of the joint surface. Once set, the mould is inserted into the robot and an optical scan of the surface is taken followed by automatic surface registration, bringing the optical scan into the same coordinate frame of reference as the CT data and plan. The CNC drill is orientated such that the drill axis and position exactly matches the planned axis and position with respect to the moulded surface. A guide hole is drilled into the mould blank, which is removed from the robot and placed back into the patient with the moulded surface ensuring exact replacement. A wire is subsequently driven through the guide hole into the osseous anatomy in accordance with the preoperative plan. The guide blank may be slid off the wire and discarded allowing the procedure to continue in the normal manner. A Pre-clinical prototype robot was constructed and used to insert guide wires into a 12 cadaveric shoulder arthroplasty specimens according to a ‘pre-operative’ plan. A ‘postoperative’ CT scan was used to assess accuracy with respect to the ‘pre-operative’ plan. Initial average end to end accuracy was 1.2 mm with respect to planned vs achieved glenoid point of entry and 2.2deg version, 1.6deg inclination with respect to planned vs achieved wire angle. These data demonstrate accuracy within the bounds of relevant literature with a significant margin for potential improvement.

The ageing population has led to recent increases in musculoskeletal conditions, with muscle weakness a major contributor to functional decline. Understanding the early phases of muscle weakness will help devise treatments to extend musculoskeletal health. Little is understood of the effects of muscle weakness on everyday activities such as sit-to-stand, a determinant of mobility that, in the early stages of weakness, requires upper limb compensation. This experimental and computational modelling study investigated the effects of muscle weakness on upper-extremity muscle forces of 27 healthy adults when using arm rests. Weakness of 29 upper limb muscles was simulated by individually removing each from a musculoskeletal model. Serratus anterior weakness was highlighted as detrimental, with the model unable to fully solve the loadsharing redundancy in its absence, and forces at the elbow and glenohumeral joint and in other muscles were found to be profoundly increased. Its large number of fast-twitch muscle fibres, predisposed to atrophy with age, highlight the centrality of the serratus anterior as a key determinant of mobility in this critical task and a potential source of early immobility through its preferential loss of strength and thus point to the requirement for early clinical interventions to mitigate loss.

An os acromiale occurs when any of the primary ossification centres of the acromion fail to fuse with the basi-acromion. It is present in approximately 8% of individuals, and whilst the majority of these individuals are unaffected it can cause significant pain and disability. It can impact seemingly unrelated surgical intervention in the region such as subacromial decompression and reverse shoulder arthroplasty. A painful os acromiale can be both a diagnostic challenge, and difficult to manage. There remain a wide variety of surgical practices with variable outcomes achieved. We present an evidence-based discussion of the surgical techniques described to date in the literature, alongside a comprehensive review of the incidence and pathophysiology of os acromiale. This review was written after a comprehensive analysis of the literature to date relating to os acromiale. Particular focus was given to material examining surgical management techniques, and the condition’s incidence across different population groups. Open reduction and internal fixation using cannulated screws, or tension band wiring have superior outcomes in the literature in the treatment of symptomatic os acromiale. There may be a biomechanical advantage of combining the two techniques. Preservation of large anterior deltoid attachment is necessary, with consideration being given to the local blood supply. There is likely no additional benefit from iliac crest vs local bone grafting. Research in this area remains of a low evidence level with small samples sizes. Appropriately powered clinical research of a higher-level evidence methodology is needed in order to differentiate further in the choice of surgical intervention. Cite this article: EFORT Open Rev 2019;4:525-532. DOI: 10.1302/2058-5241.4.180100

Digital operation of linear ion guides allows them to operate as traps and mass filters by modulating the duty cycles of the two driving waveforms. A gas-filled (5 mTorr) digitally driven quadrupole ion guide was used to demonstrate ion isolation and preconcentration. These abilities allow ion trapping mass spectrometers to be filled to capacity with only ions in the range of interest at essentially any value of m/z. Due to the unique performance characteristics of digitally operated quadrupoles, isolation with purely duty cycle enhanced waveforms was developed with three increasingly sophisticated isolation methods. First, the guide was used as a gas-filled transmission mass filter using the waveform duty cycle to generate a narrow mass window. The second method used broadband trapping to collect ions and translationally cool along the transmission axis before shifting the duty cycle to filter the trapped ions. A subsequent duty cycle change axially ejected the filtered population for measurement. The third method improved resolution by shifting the operating frequency during isolation. The resolving power was optimized with the shift frequency to yield a device limited resolving power of 400 (m/Δm). It is the temporal control of the duration of the isolation process that sets digital waveform based isolation apart from the current technology and that minimizes ion loss even when the mass is very large. Preconcentration by repeated trapping and isolation of an individual charge state was also demonstrated to saturate the ion guide with that charge state. These digital isolation and preconcentration techniques will permit the same isolation resolution (m/Δm) at any value of mass or m/z without significant ion loss as long as the secular frequencies do not significantly overlap while in the trapping mode. It is therefore ideal for the isolation and preconcentration of single charge states of large proteins and complexes.

Objectives The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes. Methods A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed. Results Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009). Conclusion This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria. Cite this article: S. Sabharwal, N. K. Patel, D. Griffiths, T. Athanasiou, C. M. Gupte, P. Reilly. Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysisBone Joint Res 2016;5:470–480. DOI: 10.1302/2046-3758.510.2000638.

Since their introduction, digital quadrupole mass spectrometers have described by analogy to traditional sinusoidal devices. However, digital quadrupoles exhibit unique behaviors and simplify many complex ion handling operations due to their uniquely flexible control over the frequency, duty cycle and amplitude of applied potentials. Matrix solutions to the Hill differential equation are used to explore the effects of these additional degrees of freedom on ion stability. Two parameters are explored: varying the frequency ratio of the applied potentials introduces a predictable number of bands of instability to the stability diagram. Varying the amplitude ratio of the applied potentials tunes the width of those unstable bands. Stability diagrams governing a digital mass filter employing asymmetric driving potentials to generate an arbitrary number of pass bands of adjustable width are systematically described.

By 2050 the proportion of over 65s is predicted to be 20% of the population. The consequences of an age-related reduction in muscle mass have not been fully investigated and, therefore, the aim of the present study was to quantify the muscle and joint contact forces using musculoskeletal modelling, during a sit-to-stand activity, to better explain difficulties in performing everyday activities for older people. A sit-to-stand activity with and without the use of arm rests was observed in ninety-five male participants, placed into groups of young (aged 18–35 years), middle-aged (aged 40–60 years) or older adults (aged 65 years and over). Older participants demonstrated significantly lower knee extensor and joint forces than the young when not using arm rests, compensating through elevated hip extensor and ankle plantarflexor muscle activity. The older group were also found to have higher shoulder joint contact forces whilst using arm rests. This tendency to reorganise muscle recruitment to include neighbouring groups or other parts of the body could make everyday activities more susceptible to age-related functional decline. Reductions in leg strength, via age- or atrophy- related means, creates increased reliance on the upper body and may result in further lower limb atrophy through disuse. The eventual decline of upper body function reduces strength reserves, leading to increased vulnerability, dependence on others and risk of institutionalisation.

The quadrupole acceptance of sinusoidal mass filters has been an area of interest for over fifty years. More recently, frequency dynamic rectangular waveform driven mass filters (colloquially digital mass filters) have been demonstrated. The acceptance of these devices has not been investigated. Commonly the acceptance of a quadrupole mass filter is calculated using the method of ellipses. Earlier this year, our group introduced an alternative method of calculating acceptance planes. The plane method is a simple and fast approach compared to ellipses. In this work, sinusoidal and digital RF driven mass filters modeled in stability zones A and B are explored using the plane method. The acceptance behavior of systems in zone B differ greatly from their zone A counterparts. There are considerable differences between the mass filter types operated in zone B. The type of RF drive potential plays an important role in the behavior of filters modeled in zone B.

Background Patient satisfaction in consenting is a major pillar of clinical governance and healthcare quality assessment. The purpose was to observe the effect of using 3D anatomical models of knee and shoulder joints on patient satisfaction during informed consent in the largest single-blinded randomised controlled trial in this field. Methods 52 patients undergoing elective knee or shoulder surgery were randomised into two groups when being consented. The intervention group (n = 26) was shown an anatomical model of the knee/shoulder joint while the control group (n = 26) was given only a verbal explanation without a model. Patients rated their satisfaction on the validated Medical Interview Satisfaction Scale (MISS-26) questionnaire. Semi-structured interviews were analysed for specific themes to determine key factors that influenced patient satisfaction. The mean score ±SD were calculated with significance set at p Results There was a significant difference in the overall satisfaction between the control and intervention cohorts (MISS-26 score 4.33 [86.6%] ± 0.646 vs 4.70 [94.0%] ± 0.335 respectively, 7.4% improvement, 8.5% difference, p = 0.01). Behavioural criteria showed a 13% increase in satisfaction (p = 0.02). Semi-structured interviews determined that the factors influencing satisfaction included the surgeon's interpersonal manner, the use of the visual aid and seeing the consultant surgeon in clinic. All patients in the intervention cohort identified factors contributing to their satisfaction, whereas a fifth of the control cohort claimed nothing at all made them feel satisfied. Conclusion Anatomical models as visual aids significantly increased patient satisfaction during the consenting process and played an integral part of the surgeon's explanation. Patients exposed to anatomical models also claimed to be more satisfied with the surgeon's inter-personal skills. This study recommends the use of anatomical models, which are both cost-effective and easily implementable, during explanation and consent for orthopaedic procedures.

International audience; IntroductionTotal Shoulder Arthroplasty (TSA) anatomical, reverse or both is an increasingly popular procedure but the glenoid component is still a weak element, accounting for 30–50% of mechanical complications and contributing to the revision burden. Component mal-positioning is one of the main aetiological factors in glenoid failure and thus Patient-Specific Instrumentation (PSI) has been introduced in an effort to optimise implant placement. The aim of this systematic literature review and meta-analysis is to compare the success of PSI and Standard Instrumentation (STDI) methods in reproducing pre-operative surgical planning of glenoid component positioning.Material and methodsA search (restricted to English language) was conducted in November 2017 on MEDLINE, the Cochrane Library, EMBASE and ClinicalTrials.gov. Using the search terms “Patient-Specific Instrumentation (PSI)”, “custom guide”, “shoulder”, “glenoid” and “arthroplasty”, 42 studies were identified. The main exclusion criteria were: no CT-scan analysis results; studies done on plastic bone; and use of a reusable or generic guide. Eligible studies evaluated final deviations from the planning for version, inclination, entry point and rotation. Reviewers worked independently to extract data and assess the risk of bias on the same studies.ResultsThe final analysis included 12 studies, comprising 227 participants (seven studies on 103 humans and five studies on 124 cadaveric specimens). Heterogeneity was moderate or high for all parameters. Deviations from the pre-operative planning for version (p10° of deviation or 4mm) were significantly higher with STDI than with PSI (68.6% vs 15.3% (p = 0.01)).ConclusionThis review supports the idea that PSI enhances glenoid component positioning, especially a decrease in the number of outliers. However, the findings are not definitive and further validation is required. It should be noted that no randomised clinical studies are available to confirm long-term outcomes.

With advances in the precision of digital electronics, waveform generation technology has progressed to a state that enables the creation of m/z filters that are purely digitally driven. These advances present new methods of performing mass analyses that provide information from a chemical system that are inherently difficult to achieve by other means. One notable characteristic of digitally driven mass filters is the capacity to transmit ions at m/z ratios that vastly exceed the capabilities of traditional resonant systems. However, the capacity to probe ion m/z ratios that span multiple orders of magnitudes across multiple orders of magnitude presents a new set of issues requiring a solution. In the present work, when probing multiply charged protein species beyond m/z 2000 using a gentle atmospheric pressure interface, the presence of solvent adducts and poorly resolved multimers can severely degrade spectral fidelity. Increasing energy imparted into a target ion population is one approach minimizing these clusters; however, the use of digital waveform technology provides an alternative that maximizes ion transport efficiency and simultaneously minimizes solvent clustering. In addition to the frequency of the applied waveform, digital manipulation also provides control over the duty cycle of the target waveform. This work examines the conditions and approach leading to optimal digital waveform operation to minimize solvent clustering. Graphical Abstract ᅟ.

Introduction Un Critical Shoulder Angle (CSA) anormal a ete identifie comme un element participant a la survenue de pathologies comme les lesions de la coiffe des rotateurs (CSA important) ou l’omarthrose (CSA faible) dans de multiples etudes cliniques. Les hypotheses biomecaniques pour expliquer ces phenomenes sont qu’une modification du CSA entraine un changement des forces en cisaillement et en compression au niveau gleno-humeral. L’objectif de cette etude etait d’evaluer les consequences biomecaniques d’une modification du CSA en utilisant un simulateur informatique de l’articulation de l’epaule valide. Materiels et methodes Le modele musculo-squelettique tridimensionnel a dynamique inversee du membre superieur UKNSM (United Kingdom National Shoulder Model) a ete utilise. Trois conditions de CSA ont ete testees (CSA normal a 33°, CSA important a 38° et CSA diminue a 28°) lors de 2 types de mouvements (abduction et flexion de 30° a 120° d’amplitude) et a 2 vitesses differentes (lente ou rapide). Les parametres suivants ont ete analyse : – la magnitude (maximum et somme sur l’ensemble de l’amplitude) des forces de cisaillement gleno-humerales (SF) correspondant aux forces infero-superieur (IS) et antero-posterieur (AP) exercees dans le plan sagittal lors des mouvements, – la magnitude (maximum et somme sur l’ensemble de l’amplitude) des forces de compression gleno-humerales (CF) correspondant aux forces latero-mediales (LM) exercees dans le plan frontal lors des mouvements. Resultats Une augmentation du CSA entraine une augmentation des forces de cisaillement notamment de la composante infero-superieure (p > 0,05). Une reduction du CSA a pour consequence une augmentation des forces de compression (latero-mediales) gleno-humerale (p > 0,01). Le type de mouvement ou la vitesse n’avait pas d’influence significative sur ces resultats. Discussion La simulation informatique est la technique la plus aboutie et validee pour reproduire et analyser la biomecanique d’une articulation. Avec un CSA augmente, le vecteur des forces du deltoide est plus vertical, entrainant plus de forces en cisaillement, necessitant donc une augmentation des forces de la coiffe postero-superieure (pour contrebalancer) conduisant a une surutilisation et a therme a une rupture. Avec un CSA diminue, le vecteur des forces du deltoide est plus oblique (en interne), et donc en addition des forces de la coiffe des rotateurs, il y a une augmentation des forces en compression sur le cartilage generant une arthrose. Conclusion Cette etude avec un simulateur informatique de l’epaule confirme, d’un point de vue biomecanique, les donnees cliniques a propos des theories sur le CSA.

Aims The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost. Methods A detailed inpatient treatment pathway was constructed using semi-structured interviews with 32 members of hospital staff. Its content validity was established through a Delphi panel evaluation. Costs were calculated using time-driven activity-based costing (TDABC) and sensitivity analysis was performed to evaluate the determinants of cost Results The mean cost of the different surgical treatments was estimated to be £3282. Although this represented a profit of £1138 against the national tariff, hemiarthroplasty as a treatment choice resulted in a net loss of £952. Choice of implant and theatre staffing were the largest cost drivers. Operating theatre delays of more than one hour resulted in a loss of income Discussion Our findings indicate that the national tariff does not accurately represent the cost of treatment for this condition. Effective use of the operating theatre and implant discounting are likely to be more effective cost containment approaches than control of bed-day costs. Take home message: This cost analysis of fractures of the proximal humerus reinforces the limitations of the national tariff within the English National Health Service, and underlines the importance of effective use of the operating theatre, as well as appropriate implant procurement where controlling costs of treatment is concerned. Cite this article: Bone Joint J 2016;98-B:249–59.

Previously our group developed spreadsheet based programs for facile production of stability diagrams because any change in the duty cycle of the rectangular waveforms changes their shape. In this publication, these programs have been extended to calculate the pseudopotential well depth of quadrupolar fields in each orthogonal direction for all values of the Mathieu parameter, q. These results were extended to 3D sinusoidal ion traps and the map of the pseudopotential well depth as a function of q was compared to the literature for validation. The duty cycle of digital ion trap waveforms was then varied to observe the change in the pseudopotential wells in each direction. Duty cycle was then manipulated with the goal of enhancing the capabilities and performance of the ion traps.

Fractures of the coracoid process are uncommon and when they do occur, are often mistaken for injuries to the acromi oclavicular joint. We report a case of a 15-year-old boy who sustained a Salter-Harris Type 1 fracture through his coracoid process alongside strain of the acromioclavicular and coracoclavicular ligaments. Additional imaging, specifically MRI, was critical in both correctly identifying this injury as a coracoid process fracture and also in determining that conservative management was the best course of action. Optimum management of such injuries remains controversial, specifically with regards to skeletally immature patients. In our case, the injury was identified clearly on MRI and managed conservatively, with the patient making a full recovery and a return to contact rugby after 3 months.

The labrum contributes to passive glenohumeral joint stability. Cadaveric studies have demonstrated that this has position and load dependency, which has not been quantified under physiological loads. This study aims to validate subject-specific finite element (FE) models against in vitro measurements of joint stability and to utilise the FE models to predict joint stability under physiological loads. The predicted stability values were within ± one standard deviation of experimental data and the FE models showed a reduction in stability of 10-15% with high, physiological, loads. The developed regression equations provide the first representation of passive glenohumeral stability and will aid surgical decision-making.

Background The aim of this study was to examine the effect of arm position on proximal humerus fracture configuration and to determine whether cortical thinning would predispose to fracture propagation and more complex patterns of injury. Methods A drop test rig was designed to simulate falls onto an outstretched arm (‘parachute reflex’). Thirty-one cadaveric specimens underwent computer tomography scanning and cortical thicknesses mapping. Humeri were fractured according to one of the two injury mechanisms and filmed using a high-speed camera. Anatomical descriptions of the injuries were made. Areas of thinning were measured and correlated with zones of fracture propagation. Results Direct impact simulation resulted in undisplaced humeral head split fractures in 53% of cases, with the remainder involving disruption to the articular margin and valgus impaction. Alternatively, the ‘parachute reflex’ predominantly produced shield-type injuries (38%) and displaced greater tuberosity fractures (19%). A strong correlation was demonstrated between cortical thinning and the occurrence of fracture (odds ratio = 7.766, 95% confidence interval from 4.760 to 12.669, pConclusion This study has shown that arm position during a fall influences fracture configuration of the proximal humerus. Correlating fracture pattern and mechanism of injury will allow more appropriate fracture reduction techniques to be devised.

Background Detachment of the central tendon of the supraspinatus from its insertion is considered to be crucial to functional deficit. The aim of the present study was to assess the function of the supraspinatus in terms of abduction moments by introducing different tear configurations to assess the functional effect of the central tendon insertion. Methods Ten fresh frozen shoulders from five cadavers were prepared for testing. A testing protocol was established to measure the abduction moment of the supraspinatus under physiological loading tailored to the anthropometrics of each specimen. Four conditions were tested: intact supraspinatus; complete detachment of portion of the supraspinatus tendon anterior to the main central tendon; detachment of the main central tendon; and detachment of the region of the supraspinatus posterior to the main central tendon. Results There was a significant and large reduction in abduction moment when the central tendon was sectioned ( p Conclusions The central tendon is vital in the role of functional arm abduction through force transmission through the intact rotator cuff. Reinsertion of the central tendon in the correct anatomical location is desirable to optimize functional outcome of surgery.

Ion traps and guides are integral parts of current commercial mass spectrometers. They are currently operated with sinusoidal waveform technology that has been developed over many years. Recently, digital waveform technology has begun to emerge and promises to supplant its older cousin because it presents new capabilities that result from the ability to instantaneously switch the frequency and duty cycle of the waveforms. This manuscript examines these capabilities and reveals their uses and effects on instrumentation. Graphical Abstract ᅟ.

The acceptance of quadrupole mass filters is improved when the alternating current (AC) and direct current (DC) fields are developed separately. Physically, this is achieved when a short RF only quadrupole (prefilter) is situated directly ahead of the mass filter. The acceptance gained by a system operating with a prefilter can be observed as an increase in sensitivity over conventional operation. Frequency dynamic duty cycle based rectangular waveform driven (rectangular wave) mass filters, a recent development, currently do not operate with prefilters. Little is known about the influence of duty cycle changes on the acceptance of rectangular wave mass filters. The sensitivity gain seen by conventional systems operating with prefilters indicates that the sensitivity of duty cycle based rectangular wave systems should increase comparably. The objective of this work was to determine prefilter efficacy for nonspecific rectangular wave mass filter systems. In this work, the plane method of acceptance was used to model the change to the acceptance and transmittance of sine and rectangular waveform driven mass filters under different modes of field development. Both systems indicated a fourfold increase in sensitivity when the mass filtering DC or duty cycle was delayed.

This publication demonstrates the use of digital waveform manipulation in linear ion guides to trap isolated ions and fragment them before mass analysis by time-of-flight mass spectrometry (TOF-MS). Ion trapping and collection was performed by waveform duty cycle manipulation to create a negative axial potential between the rods and the end-cap electrodes. Ion isolation can be performed by duty cycle manipulation to narrow the range of stable masses while continuing to axially trap the ions. Further ion isolation can then be performed by jumping the quadrupole frequency to each side of the stability zone to eliminate ions above and below the isolated ion mass. Collision-induced dissociation was demonstrated by duty cycle manipulation to either axially or radially excite the ions. The methods for performing these types of excitations are discussed and demonstrated. These techniques can be combined or used separately for MS(n) analysis. The use of frequency and duty cycle manipulation of the applied waveforms simplifies the hardware while greatly increasing the capabilities of linear ion guides and quadrupole time-of-flight mass spectrometers (Q-TOF-MS). Linear quadrupoles can now be used as high efficiency ion traps for collection, isolation, and tandem mass spectrometry at any value of m/z when operated digitally.

Spreadsheet based programs for facile production of stability diagrams have been developed to accommodate the need for rapid generation for any change in the duty cycle of rectangular waveforms. In this publication, we have used these programs to demonstrate the effects of duty cycle manipulation and visually revealed the changes in the stability diagrams for each change. The concept of equating duty cycle change with a change in the Mathieu parameter a has been reexamined and found to be incorrect with respect to matrix methods definitions. The suggestion that the 50% duty cycle stability region can be mapped by varying the duty cycle to scan along lines of constant a / q is also shown to be incorrect. These observations were possible because the spreadsheet program allowed quick alteration of the waveforms and then observation of the stability results. Finally, the needs of the operator were examined. Because the stability diagrams have to be recalculated with each change in duty cycle, it is more helpful to use the matrix methods to directly calculate the stability diagrams at a = 0 as a function of m / z and frequency. It is our intention to make these spreadsheet programs freely available to facilitate the mainstreaming of digital ion trap and guide technology.

Simulation and matrix methods were used to determine the change in the minimum trapping frequency during duty cycle base waveform manipulation to provide axial trapping. Duty cycle based axial trapping sets both rod sets of a digitally driven linear quadrupole to the same potential thereby nullifying the radial trapping field for a definable interval during the waveform cycle. Turning off the radial trapping field affects the ion motion. Consequently, the ion stability conditions and the secular frequency change with duty cycle during axial trapping. The work presented here demonstrates the change in the ion motion by simulating the ion trajectories under duty cycle base trapping conditions and determining the change in the minimum trapping frequency as a function of the change in duty cycle. The change in the stability conditions with duty cycle was determined by matrix methods. These calculations were used to determine the minimum trapping frequency change with duty cycle and validate the simulations. They were then used to discuss the duty cycle effects and propose methodology for using duty cycle waveform manipulation to perform precise ion isolation. Finally, matrix methods were used to show that ion isolation can be performed concurrently with duty cycle based axial trapping. These results were confirmed by simulation.

The incidence of proximal humeral trauma continues to rise. Treatment of complex proximal humeral trauma remains challenging and controversial. So far, classification of humeral fractures is an unsatisfactory process. In this paper we explore how we make decisions in this unique setting and present early results of using Markov Chain Monte Carlo modeling to assess concepts in surgical pattern recognition.