Lateral or Medial Parapatellar Surgical Approach to the Valgus Osteoarthritic Knee? A Retrospective Single-Center Study.

Aims: Total knee arthroplasty in patients with fixed valgus deformity is a demanding procedure. The aim of this study was to compare the clinical results of using the lateral approach [LA] versus the medial approach [MA] in the treatment of fixed valgus knee deformities. Methods: This single-center study compared the results of 143 consecutive patients with fixed valgus deformity (mean 21.55° valgus, mean age 68.2 years) undergoing LA Total Knee Arthroplasty [TKA] to 50 patients (mean 16.58° valgus, mean age 67.2 years) undergoing MA TKA. The mean follow-up period was 5.1 years (2−10 years). Data was collected from operative notes, routine postoperative visits, and radiological findings. Apart from a radiological evaluation, patients were clinically assessed both pre- and postoperatively using the Knee Society Score [KSS]. Descriptive statistics together with the Kolmogorov-Smirnov test, the Student's t-test for independent samples, and the Mann-Whitney U test were used. The level of significance in this study was α = 0.05. Results: In the LA group, the KSS Knee was significantly higher than in the MA group [85.31 vs. 77.42, respectively, p-value < 0.001]. The difference was also in the KSS total but with no statistical significance [155.17 vs. 149.22, p-value 0.087]. The surgery time in the LA group was shorter than in the MA group [81 vs. 91 min, respectively, p-value­0.002]. The complication rate after surgery was higher in the MA group than in the LA group (14% vs. 9%, respectively). Conclusions: The lateral approach is a good alternative to the standard medial parapatellar approach in the treatment of fixed valgus knee deformities. A higher postoperative KSS Knee, shorter surgery time, and similar complication rate make the lateral approach a valuable option for treating patients with osteoarthritis and fixed valgus knee deformity.

Development of Curricular Milestones for Hospice and Palliative Medicine Fellowship Training in the U.S.

CONTEXT: A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define curricular milestones (CMs) for hospice and palliative medicine (HPM) Fellowship Programs. The developed list of CMs would serve as components upon which to organize curriculum and standardize what to teach during training. These would complement entrustable professional activities previously developed by this group and new specialty-specific reporting milestones (RMs) for HPM developed through the Accreditation Council for Graduate Medical Education. OBJECTIVES: The objective of this study was to develop and vet CMs for HPM fellowships in the U.S. METHODS: A draft of CMs was developed through an iterative consensus group process with repeated cycles of drafting, analyzing, and revising by a broadly representative expert workgroup who then gained input from HPM educators at a national meeting workshop. The CM draft was subsequently revised and then vetted through a national survey to 203 fellowship educators. Respondents were asked to "keep," "revise," or "exclude" each proposed CM with space for comments. An agreement of 75% among respondents was set as the criteria a priori for keeping a CM. Eighty-four of the 203 potential respondents participated in the survey. All items met the minimum agreement level of 75% or greater recommending keeping the CM. Greater than 85% of the respondents agreed to keep 19 of the 22 CMs with no revisions. Comments for revisions on other CMs were primarily related to changes in language and formatting, not conceptual underpinnings. CONCLUSION: A group consensus method strengthened by inclusion of a national survey to HPM fellowship educators resulted in a CM document that is both carefully developed and broadly vetted. Along with entrustable professional activities and new specialty-specific RMs, these CMs offer educators and trainees tools to create more comprehensive curricula and behaviorally based assessment tools for HPM fellowships and their stakeholders.

Development of Entrustable Professional Activities for Hospice and Palliative Medicine Fellowship Training in the United States.

CONTEXT: Entrustable Professional Activities (EPAs) represent the key physician tasks of a specialty. Once a trainee demonstrates competence in an activity, they can then be "entrusted" to practice without supervision. A physician workgroup of the American Academy of Hospice and Palliative Medicine sought to define Hospice and Palliative Medicine (HPM) EPAs. OBJECTIVE: The objective of this study was to describe the development of a set of consensus EPAs for HPM fellowship training in the United States. METHODS: A set of HPM EPAs was developed through an iterative consensus process involving an expert workgroup, vetting at a national meeting with HPM educators, and an electronic survey from a national registry of 3550 HPM physicians. Vetting feedback was reviewed, and survey data were statistically analyzed. Final EPA revisions followed from the multisource feedback. RESULTS: Through the iterative consensus process, a set of 17 HPM EPAs was created, detailed, and revised. In the national survey, 362 HPM specialists responded (10%), including 58 of 126 fellowship program directors (46%). Respondents indicated that the set of 17 EPAs well represented the core activities of HPM physician practice (mean 4.72 on a five-point Likert scale) and considered all EPAs to either be "essential" or "important" with none of the EPAs ranking "neither essential, nor important." CONCLUSIONS: A set of 17 EPAs was developed using national input of practicing physicians and program directors and an iterative expert workgroup consensus process. The workgroup anticipates that EPAs can assist fellowship directors with strengthening competency-based training curricula.

Short and mid term results of revision total knee arthroplasty with Global Modular Replacement System.

BACKGROUND: The original knee megaprostheses with fixed or rotating hinge articulation were custom made and only used for reconstruction of the knee following distal femoral or proximal tibial tumor resections. The aim of the study was to analyze the short- and mid-term results of revision total knee arthroplasty with Global Modular Replacement System (GMRS) used in difficult situations not amenable to reconstruction with standard total knee replacement implants. MATERIALS AND METHODS: Nine patients (9 knees) were treated with this comprehensive modular implant system, with a mean age of 73.7 years (range 56-83 years) and a mean followup of 5 years (range 3-8 years). Two patients were treated for distal femoral nonunion, five for distal femur periprosthetic fracture and two for periprosthetic joint infection. RESULTS: The mean Knee Society Score: Knee and functional scores were 77.9 and 40 points, respectively. All demonstrated full extension and flexion was at least 90°. Recurrence of infection was present in one patient. No signs of loosening, dislocation, or implant failure were observed. CONCLUSIONS: Based on our small series of patients that represent severe cases, GMRS provides relatively good mid-term functional results, pain relief, and good implant survivorship with a low complication rate. This salvage procedure allows elderly, infirm patients to regain early ambulatory ability.

The use of calcium carbonate beads containing gentamicin in the second stage septic revision of total knee arthroplasty reduces reinfection rate.

BACKGROUND: The aim of the study was to analyze effectiveness and safety of packing the medullary canal of the tibia and femur with Herafill (Heraeus Medical GmbH, Wehrheim, Germany), a void filler and antibiotic carrier, during second stage revision total knee arthroplasty (TKA) for periprosthetic joint infection (PJI). METHODS: Two groups were formed of 28 consecutive patients during second stage revision TKA, comparable for gender and age. The study group received Herafill, while the control group did not. The average follow-up was 52 months (minimum 36 months). RESULTS: No reinfections were observed in the study group, while five were seen in the control group. No other differences were observed between the study and control groups, including mean clinical KSS (Knee Society score) (67.4 and 68.4 points, respectively) and functional score (72.5 and 70.5 points respectively). No side effects related to the use of Herafill beads were noted. CONCLUSIONS: Herafill packed into the tibial and femoral intramedullary canal during second stage of septic revision TKA is a reliable bone substitute, may reduce recurrence of infection and incorporates well with host bone. However, results after PJI treatment are less than optimal measured by KSSs as compared to patients who do not require revision.

One-stage total knee arthroplasty with pre-existing fracture deformity: post-fracture total knee arthroplasty.

The aim of the study was to assess the results of treating knee osteoarthrosis with total knee arthroplasty (TKA) after previous tibia and/or femur fractures resulting in axial limb deformities. Thirty-six knees (34 patients) were operated on. At the most recent follow-up, 4.8 years after surgery, all but one patient demonstrated an improvement in both clinical and functional KSS. This male patient required revision after 2 years. Improved range of motion was generally noted, especially extension, however, two patients with both tibia and femur fractures had worse results. TKA is an effective method of treatment for patients with arthrosis after a previous femur or tibia fractures. When deformity is severe semi-constrained or constrained, implants with extensions may be necessary.

Palliative medicine referral in patients undergoing continuous renal replacement therapy for acute kidney injury.

BACKGROUND: Referral patterns for palliative medicine consultation (PMC) by intensivists for patients requiring continuous renal replacement therapy (CRRT) have not been studied. METHODS: We retrospectively analyzed clinical data on patients who received CRRT in a tertiary referral center between 1999 and 2006 to determine timeliness and effectiveness of PMC referrals and mortality rate as a surrogate for safety among patients receiving CRRT for acute kidney injury. RESULTS: Over one-fifth (21.1%) of the 230 CRRT patients studied were referred for PMC (n = 55). PMC was requested on average after median of 15 hospital and 13 intensive care unit (ICU) days. Multivariate regression analysis revealed no association between mortality risk and PMC. Total hospital length of stay for patients who died after PMC referral was 18.5 (95% CI = 15-25) days compared with 12.5 days (95% CI = 9-17) for patients who died without PMC referral. ICU care for patients who died and received PMC was longer than for patients with no PMC [11.5 (95% CI = 9-15) days vs. 7.0 (95% CI = 6-9) days, p < 0.01]. CRRT duration was longer for patients who died and received PMC referral than for those without PMC [5.5 (95% CI = 4-8) vs. 3.0 (95% CI = 3-4) days; p < 0.01]. CONCLUSIONS: PMC was safe, but referrals were delayed and ineffective in optimizing the utilization of intensive care in patients receiving CRRT. A proactive, "triggered" referral process will likely be necessary to improve timeliness of PMC and reduce duration of non-beneficial life-sustaining therapies.

[Usefulness of HA+beta-TCP in bone defects repair during revision hip and knee arthroplasty]. / Zastosowanie HA+beta-tCP w uzupelnianiu ubytków kostnych w realloplastykach stawu biodrowego i kolanowego.

BACKGROUND: Bone deficiency can present a surgical challenge during revision total hip and knee arthroplasty. The amount of bone grafts available for surgical purposes is insufficient. Synthetic bone substitutes can eliminate the risk of infection transmission. The purpose of the present study was to evaluate the clinical and radiographic outcomes of revision hip and knee arthroplasty with use of an impaction bone-grafting with HA+beta-TCP in reconstruction of bone defects. MATERIALS AND METHODS: 20 total hip revision (THR) and 10 total knee revision (TKR) were performed in 30 patients where impaction bone-grafting technique with HA+beta-TCP was used. Clinical, radiographic and CT results were assessed. Mean follow-up was 21 (11-48) months for THR and 22 (10-46) months. RESULTS: Loosening was seen in 2 cups. In one case the reoperation was performed. In the second due to massive bone loss the prosthesis was removed. No another acetabular and stem components required revision surgery. There were no knee implant migration or loosening observed. The mean total HSS score was 45.3 preoperatively and 71.5 postoperatively. The mean CRS score was 35.7 preoperatively and 73.4 postoperatively. CONCLUSIONS: The use of HA+beta-TCP with bone grafts impaction is a good method of bone defect reconstruction and can provide good short-term clinical results in revision hip and knee arthroplasty.

Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error.

Current strategies to reduce excess pain among hospitalized patients remain inadequate. New, effective approaches are urgently needed. In this prospective observational study of a performance-improvement intervention, we studied the effect of computer-generated, real-time alerts used by nurses on the rate of a medical error in pain management defined as lack of reassessment within 120 minutes from the last observation of severe pain. We also studied duration of severe pain events and frequency of treatment of opioid-related adverse effects. Analyses of 51,619 consecutive observations of severe pain were performed in monthly intervals. Significant decrease in error rate (delayed pain reassessment) was observed postintervention (mean+/-standard error [SE]: 35.8%+/-0.7%) compared with preintervention rate (56.2%+/-1.4%, P<0.0001). Among 6305 unique severe pain events examined during four months pre- and postintervention, time to resolution of severe pain decreased significantly (median time preintervention [January 2006] of 195 minutes compared with median time postintervention of 117, 106, and 101 minutes [January, April, and June 2007], P<0.0001). Hospital-wide, unanticipated monthly naloxone administration decreased postintervention (mean+/-SE: 1.48+/-0.21 per month per 1000 inpatients) compared with preintervention (2.69+/-0.35, P=0.0130). Hospital-wide implementation of real-time, computer-generated alerts identifying instances of delayed pain reassessment resulted in sustained reduction of error rate and faster resolution of severe pain without oversedation.

[Total hip arthroplasty after previous support proximal femoral osteotomy]. / Endoprotezoplastyka stawu biodrowego po osteotomii podpórczej kosci udowej.

Clinical outcome and technical difficulties observed after total hip arthroplasty (THA) subsequent to support proximal femur osteotomy were studied in 6 total hip arthroplasties. 6 patients were follow up at an average 6.2 years after THA. The average Harris hip score before THA was 57 and after 83.6. The average leg abbreviation after THA was 1.2 cm. In one case femur perforation made impossible to stem implantation. Support proximal femoral osteotomy may make routine insertion of a femoral prosthesis difficult and jeopardize the clinical and radiological outcome of future THA.

[Scorpio TS prosthesis in severe deformity and revision knee arthroplasty--preliminary report]. / Zastosowanie endoprotezy Scorpio TS w znieksztalceniach duzego stopnia oraz operacjach rewizyjnych stawu kolanowego--doniesienie wstepne.

Authors present early results of Scorpio TS prosthesis in primary and revision total knee arthoplasty due to aseptic and septic loosening. 26 arthroplasties were performed on 25 patients. There were 19 women and 6 men of age from 37 to 80 (average 68.4 years). 11 patients from this group were operated because of septic loosening. The follow up from 2 to 22 months (average 11 months). Early results were access according to Clinical Rating System of The Knee Society: 19 patients had very good and good (73%) including primaries, 1 satisfactory (4%) and 6 poor (23%) results. The satisfactory and poor results were obtained in 7 cases with septic loosening who had had four or more previous operations on the knee. Four of them had instability of prosthesis and we changed it for MRH type. In one case due to reinfection and sepsis amputation above the knee was performed. In another patient tibia fracture below stem and loosening of tibial component occurs after 6 months of revision. ORIF gave fracture union after 8 months and exchange Scorpio TS to MRH was performed. In two cases the wound problems occurred and was solved. There were no reinfection and aseptic loosening in another cases. We didn't notice any thrombosis complications.

[Modular short-stem prosthesis in total hip arthroplasty--preliminary report]. / Modularny, krótki trzpien w endoprotezoplastyce stawu biodrowego--doniesienie wstepne.

Total hip arthroplasty has become one of the most succesful procedure in orthopaedic surgery. More and more active, young patients undergo primary hip replacement. Bone stock preservation is crucial when performing THR in this group of patients. The short stem design allows a methaphyseal intratrochanteric multipoint, strong primary fixation which is very important for this group of patients. The goal is to save bone stock for the revision operation. This study presents early results of Metha short stems prosthesis. Between April 2006-December 2007, 58 short stem (Metha) were implanted. The Harris Hip Score improved from a mean 64.3 before to 89.7 at follow-up. The Metha stem may not be indicated for every hip diseases. There were only two fractures of femur without any further problems. Despite the short follow-up, Metha prosthesis already represent a valuable alternative for younger patients.

Fentanyl-induced neurotoxicity and paradoxic pain.

A patient with pain associated with metastatic leiomyosarcoma received escalating doses of opioids. Upon discontinuation of intravenous morphine, transdermal fentanyl was initiated, and after several days, the dose was increased to 200microg/hour for persistent, severe pain. The patient became somnolent, and further dose adjustments and route change were carried out. She then exhibited severe allodynia, myoclonus, and delirium thereafter fentanyl was stopped. All symptoms resolved with discontinuation of fentanyl and subsequent introduction of a weak opioid. Pain was well controlled. Gradually increasing standard doses of fentanyl may lead to severe neurotoxicity, which may respond to opioid discontinuation and/or rotation. Vigilant scrutiny of all possible causes of apparent analgesic failure followed by consideration of opioid reduction and rotation is warranted in cases of neurotoxicity accompanying opioid treatment.

Ketamine: an introduction for the pain and palliative medicine physician.

A history of an escalating chronic intractable pain in a patient with cryoglobulinemia, vasculitis, and severe cutaneous ulcerations is presented. A strategy of progressive, multi-agent, N-methyl-D-aspartate-receptor (NMDA-R) blockade that resulted in adequate pain control and a three-fold reduction in opioid consumption is described. Diagnostic process of neuropathic pain and the role of NMDA-R in the development of hyperalgesia are briefly reviewed. Thereafter, existing clinical literature describing the use of Ketamine, a major NMDA-R antagonist for management of malignant pain, is reviewed. Lastly, evidence-based original protocol for intravenous adjuvant Ketamine analgesia for severe cancer pain is presented.

"Nobody understands": on a cardinal phenomenon of palliative care.

In the clinical practice of palliative medicine, recommended communication models fail to approximate the truth of suffering associated with an impending death. I provide evidence from patients' stories and empiric research alike to support this observation. Rather than attributing this deficiency to inadequate training or communication skills, I examine the epistemological premises of the biomedical language governing the patient-physician communication. I demonstrate that the contemporary biomedicine faces a fundamental aporetic occlusion in attempting to examine death. This review asserts that the occlusion defines, rather than simply complicating, palliative care. Given the defining place of aporia in the care for the dying, I suggest that this finding shape the clinicians' responses to the needs of patients in clinical care and in designing palliative research. Lastly, I briefly signal that a genuinely apophatic voice construing the occlusion as a mystery rather than an aporia may be superior to the present communication and empathy models.

Palliative educational outcome with implementation of PEACE tool integrated clinical pathway.

BACKGROUND: House officers frequently lack basic competency in end-of-life care. Few studies have evaluated educational interventions deliberately utilizing physicians' learning strategies, particularly in the context of a concomitant effort at modification of practice patterns. STUDY DESIGN: Prospective controlled trial utilizing pre-intervention and post-intervention cross-sectional surveys. PARTICIPANTS: Internal medicine residents at a university hospital in their first, second, and third years of training. SURVEY: A 25-item survey modified from previously published instruments. INTERVENTION: Residents in the intervention group utilized an experiential learning intervention (integrated, end-of-life clinical pathway: PEACE Tool). The control group delivered care in a standard fashion. DATA ANALYSIS: SURVEY item and test responses were tabulated and pair-wise comparisons between group means evaluated statistically using two-sample t tests. RESULTS: Fifty-four internal medicine residents (n = 24, first-year; n = 17, second-year; and n = 13, third-year) completed the survey. Pre-intervention mean scores on a 16-item knowledge scale were 7.4 (46% correct) for first-year, 8.1 (51%) for second-year, and 9.2 (58%) for third-year residents. Eighteen first-year residents participated in the intervention phase (8 in the intervention, 10 in the control). Mean overall knowledge scores were 46% higher in the intervention group compared to the control group (11.8 versus 8.1 p < 0.001). CONCLUSIONS: A time-effective, practice-based strategy led to a significant improvement in knowledge of end-of-life care. Prior to implementation of this strategy competency in end-of-life care was suboptimal among internal medicine residents, in spite of desirable attitudes. Factual knowledge improved slightly with standard, pre-intervention training and experience.