15-year experience with soft tissue expansion in total knee arthroplasty.

Preoperative identification of a knee at risk for wound healing after total knee arthroplasty (TKA) allows the surgeon to apply a soft tissue expansion technique to expand the available tissue for closure and healing after TKA. A consecutive series of 64 soft tissue expansions were performed for 59 cases of conflicting incisions and 5 cases of severe angular deformity, with a mean of 3.5 previous surgeries. An average 2.1 expanders were used for a total volume of 359 mL. Expansion took a mean of 70 days during which 14 minor and 7 major complications occurred. There were 8 post-TKA complications, 5 of which required a return to the operating room. Soft tissue expansion is a safe, prophylactic technique that provides adequate coverage in this complex subset of patients.

Submuscular locked plating of pediatric femur fractures.

Recent advances in plating technology for the pediatric femur fracture have demonstrated early mobilization of the extremity and early weight bearing. Submuscular techniques allow for minimal soft tissue disruption and provide a theoretical healing advantage. This article presents results of the treatment of pediatric femur fractures using a locked submuscular bridge plating technique. The authors reviewed 16 patients between 6 and 12 years of age who sustained a femoral shaft fracture treated with minimally invasive submuscular locked plating. Patients were followed for an average of 25 months and made full weight bearing within 6 weeks of surgery. All patients achieved radiographic and clinical union with an average time of 2.6 months. Range of motion of the knee and hip were equivalent to the contralateral extremity at 2.1 months. Average time of hardware removal was 11 months. Benefits of locked plating of pediatric femur fractures include high union rates, early weight bearing, early recovery of range of motion, and minimal complications.

Pediatric orthopedic trauma: principles of management.

Musculoskeletal injuries in the pediatric population are unique and require a thorough evaluation by a trained specialist. Unlike adults, many of the injuries may be treated closed due to the amazing growth and remodeling potential of children. Special consideration should be taken in treating certain fracture patterns to prevent the long-term consequences of growth deformities and protect children from child abuse. It is the goal of this article to outline common orthopedic injuries in the pediatric population to facilitate proper care in the multidisciplinary evaluation and treatment of children.

Radiologic case study. Traumatic dislocation of the knee.

Imaging in knee dislocation requires multiple modalities and a comprehensive assessment of ligaments, cartilage, bone, nerve, and vascular anatomy. Magnetic resonance imaging is essential in the work-up of these patients and MRA is a promising modality for detecting vascular injury.

Lessons in flying: crew resource management as a quality improvement method for acute coronary syndromes care.

Providing timely, high-quality, guideline-based care to patients with acute coronary syndromes (ACS) who present to the emergency department is critically dependent on cooperation, coordination, and communication between emergency medicine physicians and cardiologists. However, to achieve sustained improvement at the individual institution level, consistent implementation of quality improvement (QI) activities is needed. We describe a QI initiative for ACS care in the emergency setting that combined clinical education with a curriculum based on crew resource management (CRM) principles-a set of tools and techniques for communication, teamwork, and error avoidance used in the aviation industry and with proven applicability in the healthcare setting. Educational training sessions were open to multidisciplinary healthcare teams at 3 hospital sites, and participants were provided practical tools and resources to enhance communication, teamwork, and patient-centered care. Through patient chart reviews, participant surveys, and clinician interviews, baseline assessments of clinical performance measures and team communication-, logistics-, and skills-based efficiencies were performed and reported before the educational training was delivered at each QI site. Reviews of pre- and postinitiative participant surveys demonstrated improvement in knowledge and confidence in the delivery of appropriate and effective ACS care; however, reviews of pre- and postinitiative patient charts revealed limited process improvements. Altogether, this multicenter study of a continuing medical education program based on CRM principles was associated with improvements in provider knowledge and confidence regarding the delivery of appropriate ACS care, but had limited impact on clinical performance measures.

Fatal knee dislocation in a morbidly obese Jehovah's Witness. A case report.

We describe a case of a morbidly obese Jehovah's Witness who sustained a popliteal artery and vein transection after a spontaneous knee dislocation. Following surgical repair, the patient fatally deteriorated, while blood products had to be withheld according to the patient's preoperative request.