Comparative Analysis of 3 Techniques of Scapholunate Reconstruction for Dorsal Intercalated Segment Instability.

PURPOSE: The combination of scaphoid rotatory subluxation, dorsal intercalated segment instability, and dorsal scaphoid translation (DST) constitutes stage 5 scapholunate dissociation in the modified classification system of Garcia-Elias. The purpose of this study was to compare the static radiographic outcomes of reduction and association of the scaphoid and lunate (RASL), three-ligament tenodesis (TLT), and anatomic front and back (ANAFAB) reconstructions for stage 5 scaphoid and lunate malrotation and translation. METHODS: Stage 5 scapholunate dissociation was created in 15 fresh-frozen specimens by cutting the scapholunate interosseous ligament, long radiolunate ligament, dorsal intercarpal ligament, and scaphotrapeziotrapezoid ligament complex. Specimens were randomized to receive 1 of the 3 reconstructive techniques. Radiolunate angle (RLA), scapholunate angle, scapholunate gap, and DST were measured in static fluoroscopic posteroanterior and lateral views in 3 conditions: baseline, injured, and reconstructed. RESULTS: Reduction and association of the scaphoid and lunate showed an improved correction of scapholunate gap compared with TLT and ANAFAB. Anatomic front and back demonstrated an improved correction in RLA and scapholunate angle compared with RASL but not TLT. When the reconstruction was compared with baseline, there was a persistent lunate extension for TLT (RLA and scapholunate angle) and RASL (RLA); however, no significant difference in any parameter was found with ANAFAB. Anatomic front and back significantly improved DST, whereas TLT and RASL did not. CONCLUSIONS: In this cadaveric model of scapholunate dissociation with dorsal intercalated segment instability and DST, each of the 3 repairs had different effects on carpal posture and alignment. While only RASL statistically improved scapholunate gap, only ANAFAB significantly improved DST. Both TLT and RASL improved radiographic parameters; however, each had a persistent increase in the lunate extension following reconstruction. CLINICAL RELEVANCE: It may be prudent to consider different reconstructive techniques for different stages of scapholunate instability. Anatomic front and back, a repair that addresses both dorsal and volar ligament stabilizers, provides improved reduction of dorsal intercalated segment instability and DST in stage 5 scapholunate dissociation.

Generalist Palliative Care in the California Safety Net: A Structured Assessment to Design Interventions for a Range of Care Settings.

BACKGROUND: To provide high quality care to all patients who have serious illness, health-care systems must develop effective generalist palliative care strategies. OBJECTIVE: To identify palliative care quality gaps within a range of settings in the California safety net and to develop theory-based interventions to address them. DESIGN: Structured assessment using the National Consensus Project for Quality Palliative Care Clinical Practice Guidelines and a Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation intervention planning model-based worksheet, which integrates behavior theories to identify factors that predispose, enable, and reinforce clinicians to perform recommended behaviors. SETTING AND PARTICIPANTS: Adviser pairs-one from palliative care and one from a partner service line-from 10 California public health-care systems conducted assessments at their sites. A steering committee provided educational webinars, best practices, and assessment tools. MEASUREMENTS: Adviser pairs interviewed at least 6 partner service line stakeholders to identify palliative care quality gaps, behaviors clinicians should perform to close gaps, and factors that predispose, enable, and reinforce those behaviors. RESULTS: Partner service lines were primary care (n = 4), surgery (n = 3), emergency department (n = 2), and radiation oncology (n = 1). Selected gaps were advance care planning and goals of care communication (n = 6), identifying patients with serious illness (n = 3), and pain management (n = 1). All sites designed multiple interventions to address gaps, based on factors that predispose, enable, and reinforce a target audience to perform a target behavior. Advisers reported that the program strengthened relationships between palliative care and the partner service line. CONCLUSION: This structured assessment helped busy clinicians develop theory-based generalist palliative care interventions.

The Middle and Distal Aspects of the Ulnar Footprint of the Medial Ulnar Collateral Ligament of the Elbow Do Not Provide Significant Resistance to Valgus Stress: A Biomechanical Study.

BACKGROUND: The medial ulnar collateral ligament (UCL) insertion of the elbow has been shown to extend distally beyond the sublime tubercle. The contribution to valgus stability of the distal aspect of the footprint is unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the contribution of each part of the UCL footprint to the elbow valgus stability provided by the UCL. It was hypothesized that the distal two-thirds of the ulnar UCL footprint would not contribute significantly to valgus stability provided by the UCL. STUDY DESIGN: Descriptive laboratory study. METHODS: Fifteen cadaveric arms were dissected to the capsuloligamentous elbow structures and potted. A servohydraulic load frame was used to place 5 N·m of valgus stress on the intact elbow at 30°, 60°, 90°, and 120° of flexion. The UCL insertional footprint was measured and divided into thirds (proximal, middle, and distal). One-third of the UCL footprint was elevated off the bone (leaving the ligament in continuity), and the elbow was retested at the same degrees of flexion. This was repeated until the entire UCL footprint on the ulna was sectioned. Each elbow was randomized for how the UCL would be sectioned (sectioning the proximal, then middle, and then distal third or sectioning the distal, then middle, and then proximal third). Ulnohumeral joint gapping (millimeters) was recorded with a 3-dimensional motion capture system using physical and virtual markers. Two-group comparisons were made between each sectioned status versus the intact condition for each flexion angle. RESULTS: When the UCL was sectioned from distal to proximal, none of the ligaments failed prior to complete sectioning. When the UCL was sectioned from proximal to distal, 3 of the 6 ligaments failed after sectioning of the proximal third, while 2 more failed after the proximal and middle thirds were sectioned. Of the specimens with the distal third of the ligament sectioned first, no significant differences were found between intact, distal third cut, and distal plus middle thirds cut at all flexion angles. CONCLUSION: The middle and distal thirds of the insertional footprint of the UCL on the ulna did not significantly contribute to gap resistance at 5 N·m of valgus load. The proximal third of the footprint is the primary resistor of valgus load. CLINICAL RELEVANCE: This cadaveric biomechanical study demonstrated that the middle and distal thirds of the native UCL insertion onto the ulna did not significantly contribute to valgus resistance at the elbow. When a UCL reconstruction is performed, the proximal third of the UCL insertion may be the most clinically important portion of the ligament to reconstruct.

Responding to the Language Challenge: Kaiser Permanente's Approach.

OBJECTIVE: To inform current debates on improving health care quality for patients with limited English proficiency by identifying the drivers and processes for one large health care delivery system's implementation of particular models, key success factors, and remaining challenges for the field. STUDY DESIGN: A qualitative case study of the Kaiser Permanente (KP) San Francisco Medical Center's approach to developing linguistic access services and subsequent organizationwide initiatives. METHODS: We conducted semistructured interviews with eight current and former clinical and administrative leaders from the KP San Francisco Medical Center and national headquarters. Interviews were analyzed for key themes. RESULTS: KP San Francisco Medical Center developed linguistic and cultural services in response to a confluence of external and internal factors, including changing demographics, care quality challenges, and patient and clinician satisfaction issues. Early strategies included development of language-specific care modules focused on Chinese- and Spanish-speaking members while meeting broader linguistic access and cultural-competency needs through a centralized Multicultural Services Center. Additional approaches across KP regions have focused on improving interpreter services, optimizing use of bilingual staff, and creating a translation infrastructure to improve quality and reduce redundancy in written translation efforts. CONCLUSIONS: KP's experiences developing linguistic and cultural care and services since the 1990s provide lessons about decision-making processes and approaches that may guide other health systems, insurers, and policy makers striving to improve care quality and safety for patients with limited English proficiency.

The coronal plane high tibial osteotomy. Part II: a comparison of axial rotation with the opening wedge high tibial osteotomy.

The amount of axial rotation in the tibia caused by high tibial osteotomy is relatively unknown. The authors hypothesize that the coronal plane high tibial osteotomy, a novel technique used to treat varus malalignment, alters the axial rotation of the tibia less than the opening wedge high tibial osteotomy. Eight, embalmed, stripped cadaveric tibia-fibula constructs with intact interosseous membranes were randomized to either opening wedge or coronal plane high tibial osteotomies. Sequential valgus corrections of 5 degrees, 10 degrees, and 15 degrees were performed. The Qualisys Track Manager motion capture system was used to measure axial rotation. Student's t test was used to compare axial rotation between the two groups. A p value of 0.05 was determined to be significant. The coronal plane technique produced rotations about the tibial axis that were statistically significantly smaller than those of the opening wedge technique for all correction angles (1.2 degrees internal rotation (IR) vs 16 degrees external rotation (ER), respectively, at 5 degrees correction; p = 0.02) (3.5 degrees IR vs 21.2 degrees ER at 10 degrees correction; p = 0.04) (4.5 degrees IR vs 23.0 degrees ER at 15 degrees correction; p = 0.01). The coronal plane high tibial osteotomy alters axial rotation of the tibia significantly less than the opening wedge high tibial osteotomy.