Defining growth potential and barriers to same day discharge total knee arthroplasty.

BACKGROUND: Outpatient arthroplasty programs are becoming well established. Adverse event rates have been demonstrated to be no worse than inpatient arthroplasty in the literature for selected patients. The purpose of this study was to determine our rate of outpatient total knee arthroplasty (TKA), examine justification for exclusions, and estimate the proportion of TKAs that can occur safely on an outpatient basis. METHODS: Retrospective case series of 400 consecutive TKAs from Oct 2014 to Mar 2017. Patient demographics, allocation to outpatient surgery vs standard admission, and reason for exclusion from outpatient surgery were recorded. Ninety-day Emergency department (ED) visits, readmission rates, and length of stay (LOS) were compared between groups using independent sample t test and Chi-squared test. RESULTS: Outpatients were younger (p = 0.001), had lower BMI (p < 0.001), and ASA scores (p < 0.001) than inpatients. One hundred twenty-five (31%) TKAs were assigned to outpatient surgery and 123 achieved discharge on the same day. There was no difference in 90-day ED visits (p = 0.889) or readmission rates (p = 0.338) between groups. Reasons for exclusion from outpatient surgery included medical (absolute 43% and relative 31%), distance > one hour from hospital (18%), no help (7%), and other/unclear (10%). LOS was significantly longer for medical than non-medical exclusions (p < 0.001) and for the absolute compared to relative medical exclusions (p = 0.004). CONCLUSION: Outpatient TKA is safe in selected patients, and inclusion can likely be broadened by addressing modifiable exclusions and narrowing medical exclusions. We found that 55% of our TKA population could be appropriate for outpatient surgery.

Video-based assessment (VBA) of an open, simulated orthopedic surgical procedure: a pilot study using a single-angle camera to assess surgical skill and decision making.

BACKGROUND: Videos have been used in many settings including medical simulation. Limited information currently exists on video-based assessment in surgical training. Effective assessment tools have substantial impact on the future of training. The objectives of this study were as follows: to evaluate the inter-rater reliability of video-based assessment of orthopedic surgery residents performing open cadaveric simulation procedures and to explore the benefits and limitations of video-based assessment. METHODS: A multi-method technique was used. In the quantitative portion, four residents participated in a Surgical Objective Structured Clinical Examination in 2017 at a quaternary care training center. A single camera bird's-eye view was used to videotape the procedures. Five orthopedic surgeons evaluated the surgical videos using the Ottawa Surgical Competency Operating Room Evaluation. Interclass correlation coefficient was used to calculate inter-rater reliability. In the qualitative section, semi-structured interviews were used to explore the perceived strengths and limitations of video-based assessment. RESULTS AND DISCUSSION: The scores using video-based assessment demonstrated good inter-rater reliability (ICC = 0.832, p = 0.014) in assessing open orthopedic procedures on cadavers. Qualitatively, the strengths of video-based assessment in this study are its ability to assess global performance and/or specific skills, ability to reassess missed points during live assessment, and potential use for less common procedures. It also allows for detailed constructive feedback, flexible assessment time, anonymous assessment, multiple assessors and serves as a good coaching tool. The main limitations of video-based assessment are poor audio-video quality, and questionable feasibility for assessing readiness for practice. CONCLUSION: Video-based assessment is a potential adjunct to live assessment in orthopedic open procedures with good inter-rater reliability. Improving audio-video quality will enhance the quality of the assessment and improve the effectiveness of using this tool in surgical training.

Aldehyde dehydrogenase activity of breast cancer stem cells is primarily due to isoform ALDH1A3 and its expression is predictive of metastasis.

Cancer stem cells (CSCs) are proposed to initiate cancer and propagate metastasis. Breast CSCs identified by aldehyde dehydrogenase (ALDH) activity are highly tumorigenic in xenograft models. However, in patient breast tumor immunohistological studies, where CSCs are identified by expression of ALDH isoform ALDH1A1, CSC prevalence is not correlative with metastasis, raising some doubt as to the role of CSCs in cancer. We characterized the expression of all 19 ALDH isoforms in patient breast tumor CSCs and breast cancer cell lines by total genome microarray expression analysis, immunofluorescence protein expression studies, and quantitative polymerase chain reaction. These studies revealed that ALDH activity of patient breast tumor CSCs and cell lines correlates best with expression of another isoform, ALDH1A3, not ALDH1A1. We performed shRNA knockdown experiments of the various ALDH isoforms and found that only ALDH1A3 knockdown uniformly reduced ALDH activity of breast cancer cells. Immunohistological studies with fixed patient breast tumor samples revealed that ALDH1A3 expression in patient breast tumors correlates significantly with tumor grade, metastasis, and cancer stage. Our results, therefore, identify ALDH1A3 as a novel CSC marker with potential clinical prognostic applicability, and demonstrate a clear correlation between CSC prevalence and the development of metastatic breast cancer.

Developing and Assessing the Feasibility of Implementing a Surgical Objective Structured Clinical Skills Examination (S-OSCE).

OBJECTIVE: To1 describe the development and evaluate the feasibility of a surgical objective structured clinical examination (OSCE) for the purpose of competency assessment based on the Royal College of Canada's CanMEDS framework. DESIGN: A unique surgical OSCE was developed to evaluate the clinical and surgical management of common orthopaedic problems using simulated patients and cadaveric specimens. Cases were graded by degree of difficulty (less complex, complex, more complex) Developing an assessment tool with significant resource utilization and good correlation with traditional methods is challenging. The feasibility of an OSCE that evaluates independent clinical and surgical decision making was evaluated. In addition, as part of establishing construct validity, correlation of OSCE scores with previously validated O-scores was performed. SETTING: A tertiary level academic teaching hospital. PARTICIPANTS: Thirty-four Postgraduate year 3-5 trainees of a 5-year Canadian orthopedic residency program creating 96 operative case performances available for final review. RESULTS: The development of the OSCE cases involved a multistep process with attending surgeons, residents and a surgical education consultant. There were 4 different OSCE days, over a 3 year period (2016-2018) encompassing a variety of less complex and more complex procedures. Performance on the OSCE correlated strongly with the (O-SCORE, 0.89) and a linear regression analysis correlated moderately with year of training (r2 = 0.5737). The feasibility analysis demonstrated good financial practicality with solid programmatic integration. CONCLUSIONS: The unique surgical OSCE scores correlate strongly with an established entrustability scale. Administering this OSCE to evaluate preoperative and intraoperative decision making to complement other forms of assessment is feasible. The financial burden to training programs is modest in comparison to the insight gained by both residents and faculty.