Development, Validation, and Implementation of a Guideline to Improve Clinical Event Debriefing at a Level-I Adult and Level-II Pediatric Trauma Center.

OBJECTIVE: Clinical event debriefing is recommended by the American Heart Association and the European Resuscitation Council, because debriefings improve team performance. The purpose here was to develop and validate tools needed to overcome barriers to debriefing in the emergency department. METHOD: This quality improvement project was conducted in 4 phases. Phase 1: Current evidence related to debriefing in the emergency department was reviewed and synthesized to inform an iterative process for drafting the debriefing guideline and instrument for documentation. Phase 2: Content Validity Index of the tools was evaluated by obtaining ratings of items' clarity and relevance from 5 national experts in 2 rounds of review. On the basis of experts' feedback, tools were revised, and a Facilitators' Guide was created. Phase 3: The validated debriefing tools were implemented. Phase 4: Debriefing facilitators completed a survey about their experience with using the new tools. RESULTS: The Content Validity Index of 71 debriefing tool items (guideline, instrument, Facilitators' Guide) was 0.93 and 0.96 for clarity and relevance, respectively. Of the 32 debriefings conducted during the first 8 weeks of implementation, 53% described patient safety concerns, and 97% described recommendations to improve performance. Most (94%) facilitators agreed that the guideline clarified debriefing requirements. CONCLUSION: The use of debriefing tools validated by computation of the Content Validity Index led to the identification of safety threats and recommendations to improve care processes. These tools can be used in ED settings to promote team learning and aid in identifying and resolving safety concerns.

Controlled tetra-Fc sialylation of IVIg results in a drug candidate with consistent enhanced anti-inflammatory activity.

Despite the beneficial therapeutic effects of intravenous immunoglobulin (IVIg) in inflammatory diseases, consistent therapeutic efficacy and potency remain major limitations for patients and physicians using IVIg. These limitations have stimulated a desire to generate therapeutic alternatives that could leverage the broad mechanisms of action of IVIg while improving therapeutic consistency and potency. The identification of the important anti-inflammatory role of fragment crystallizable domain (Fc) sialylation has presented an opportunity to develop more potent Ig therapies. However, translating this concept to potent anti-inflammatory therapeutics has been hampered by the difficulty of generating suitable sialylated products for clinical use. Therefore, we set out to develop the first, to our knowledge, robust and scalable process for generating a well-qualified sialylated IVIg drug candidate with maximum Fc sialylation devoid of unwanted alterations to the IVIg mixture. Here, we describe a controlled enzymatic, scalable process to produce a tetra-Fc-sialylated (s4-IVIg) IVIg drug candidate and its qualification across a wide panel of analytic assays, including physicochemical, pharmacokinetic, biodistribution, and in vivo animal models of inflammation. Our in vivo characterization of this drug candidate revealed consistent, enhanced anti-inflammatory activity up to 10-fold higher than IVIg across different animal models. To our knowledge, this candidate represents the first s4-IVIg suitable for clinical use; it is also a valuable therapeutic alternative with more consistent and potent anti-inflammatory activity.

What Preoperative Radiographic Parameters Are Associated With Increased Medial Release in Total Knee Arthroplasty?

BACKGROUND: Preoperative varus deformity of the knee is a common malalignment in patients undergoing primary total knee arthroplasty (TKA). We are unaware of any studies that have correlated how various preoperative radiographic parameters can predict the amount of medial releases performed to achieve optimal coronal alignment and ligamentous balance. METHODS: A retrospective review was performed on 67 patients who required at least a medial tibial reduction osteotomy (MTRO) during primary TKA to achieve coronal balance. This patient population was matched 1:1 to another cohort of TKA patients by age, gender, and body mass index who did not require an MTRO. A radiographic evaluation was used to compare the 2 cohorts. RESULTS: Preoperatively, the MTRO cohort was noted to have significantly increased varus tibiofemoral (86.12° vs 93.43°), tibial articular surface (85.79° vs 87.54°), and medial tibial articular surface angles (75.22° vs 85.34°) compared to the control cohort. The MTRO cohort had 3.13 mm of medial tibial offset and 9.06 mm of lateral joint space opening and the control cohort had 0.09 mm and 4.07 mm, respectively. The medial tibial articular surface angle and lateral joint space widening were statistically associated with the MTRO cohort. The final tibiofemoral angle in the MTRO cohort was 92.43° and was 93.40° in the control cohort. CONCLUSION: The MTRO cohort was noted to have several preoperative radiographic parameters that were significantly different than the control cohort. However, the medial tibial articular surface angle and lateral joint space widening were the only radiographic parameters that were statistically associated with requiring an MTRO.

Fixation versus replacement of radial head in terrible triad: is there a difference in elbow stability and prognosis?

BACKGROUND: Surgical treatment for terrible triad injuries of the elbow (defined as elbow dislocations with concomitant fractures of the radial head and coronoid) remains a challenging clinical problem. Specifically, the question of whether to repair or replace the radial head remains controversial. QUESTIONS/PURPOSES: We compared patients with terrible triad injuries of the elbow whose radial head fracture was treated with either internal fixation and internal fixation (ORIF) or radial head arthroplasty in terms of (1) clinical outcome measures (DASH and Broberg-Morrey scores, ROM), (2) elbow stability and radiographic signs of arthrosis, and (3) complications and reoperation rates. METHODS: Retrospective review identified 39 patients with terrible triad injuries and minimum 18-month complete clinical and radiographic followup (mean, 24 months; range, 18-53 months). Patients were managed with a standard algorithm consisting of (1) repair (n = 9) or replacement (n = 30) of the radial head, (2) repair of the lateral ulnar collateral ligament, and (3) repair of the coronoid fracture. During the study period, the radial head generally was internally fixed when there were fewer than four articular fragments; otherwise, it was replaced. Evaluation included the DASH score, the Broberg-Morrey index, measurements of elbow stability and motion, and radiographic assessment for signs of arthrosis; chart review was performed for complications and reoperations. Complete followup was available on 87% (39 of 45 patients). RESULTS: There were no differences between groups in terms of ROM or elbow scores. All patients who underwent radial head arthroplasty at the index procedure had a stable elbow at final followup whereas three of nine patients who underwent ORIF were unstable (p = 0.009). However, 11 patients who underwent arthroplasty demonstrated radiographic signs of arthrosis compared to none in the ORIF group (p = 0.04). Eleven patients (28%) underwent reoperation (seven arthroplasty, four ORIF) for various reasons. With the numbers available, there was no difference in reoperation rate between groups (p = 0.45). CONCLUSIONS: For terrible triad injuries, radial head arthroplasty afforded the ability to obtain elbow stability with comparable overall outcomes when compared to ORIF. As these injuries commonly occur in younger patients, longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Economic evaluation of access to musculoskeletal care: the case of waiting for total knee arthroplasty.

BACKGROUND: The projected demand for total knee arthroplasty is staggering. At its root, the solution involves increasing supply or decreasing demand. Other developed nations have used rationing and wait times to distribute this service. However, economic impact and cost-effectiveness of waiting for TKA is unknown. METHODS: A Markov decision model was constructed for a cost-utility analysis of three treatment strategies for end-stage knee osteoarthritis: 1) TKA without delay, 2) a waiting period with no non-operative treatment and 3) a non-operative treatment bridge during that waiting period in a cohort of 60 year-old patients. Outcome probabilities and effectiveness were derived from the literature. Costs were estimated from the societal perspective with national average Medicare reimbursement. Effectiveness was expressed in quality-adjusted life years (QALYs) gained. Principal outcome measures were average incremental costs, effectiveness, and quality-adjusted life years; and net health benefits. RESULTS: In the base case, a 2-year wait-time both with and without a non-operative treatment bridge resulted in a lower number of average QALYs gained (11.57 (no bridge) and 11.95 (bridge) vs. 12.14 (no delay). The average cost was $1,660 higher for TKA without delay than wait-time with no bridge, but $1,810 less than wait-time with non-operative bridge. The incremental cost-effectiveness ratio comparing wait-time with no bridge to TKA without delay was $2,901/QALY. When comparing TKA without delay to waiting with non-operative bridge, TKA without delay produced greater utility at a lower cost to society. CONCLUSIONS: TKA without delay is the preferred cost-effective treatment strategy when compared to a waiting for TKA without non-operative bridge. TKA without delay is cost saving when a non-operative bridge is used during the waiting period. As it is unlikely that patients waiting for TKA would not receive non-operative treatment, TKA without delay may be an overall cost-saving health care delivery strategy. Policies aimed at increasing the supply of TKA should be considered as savings exist that could indirectly fund those strategies.

Anatomic findings and complications after surgical treatment of chronic, partial distal biceps tendon tears: a case cohort comparison study.

PURPOSE: To describe pertinent anatomic findings during repair of chronic, partial distal biceps tendon tears and to compare the complications of surgery with a similar cohort of acute, complete tears. METHODS: Group 1 included 14 patients (15 elbows) with partial tears managed operatively an average of 10 months from onset of injury or symptoms. Group 2 included a matched cohort of 16 patients (17 elbows) treated for complete, acute tears an average of 19 days from injury. A retrospective review of all 30 patients focused on demographic data, intraoperative findings, and postoperative complications. A single, anterior incision was used in all cases with multiple suture anchors or a bicortical toggling button for fixation of the repair. RESULTS: We evaluated 27 men and 3 women with an average age of 55 years (group 1) and 48 years (group 2). Intratendinous ganglion formation at the site of rupture of the degenerative tendon was observed in 5 cases of partial tears and none of the complete tears. Partial tears involved the lateral aspect or short head of the biceps tendon insertion in all cases. Postoperative complications included lateral antebrachial cutaneous nerve neuritis in 8 group 1 patients and 6 group 2 patients and transient posterior interosseus nerve palsy in 3 group 1 patients. CONCLUSIONS: Partial distal biceps tendon ruptures showed a consistent pattern of pathology involving disruption of the lateral side of the tendon insertion involving the small head of the biceps. Degenerative intratendinous ganglion formation was present in one third of cases. Repair of chronic, partial distal biceps tendon injuries may have a higher incidence of posterior interosseous and lateral antebrachial cutaneous nerve palsies. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Risk versus reward: total joint arthroplasty outcomes after various solid organ transplantations.

Clinical outcomes were retrospectively reviewed for 76 primary total hip (THA) and total knee arthroplasties (TKA) performed after kidney, liver, cardiac, and lung transplantation with follow-up of 30.2 and 41.2 months, respectively. For the THA and TKA cohorts, there were a high rate of medical complications (29% and 33%), increased hospital length of stay (4.2 and 3.7 days), and more reoperations (7.2% and 9.1%). Only 1 (1.8%) periprosthetic infection was documented for THAs but 3 (14.2%) TKAs required two-stage revisions for infection. All transplant cohorts demonstrated significant increases (P < 0.05) in HHS and KSS scores with majority of patients reporting overall good or excellent outcomes (82%-100%). These results suggest that various organ transplant patients may accept higher surgical risks for rewarding outcomes.

Outcomes of primary total joint arthroplasty after lung transplantation.

Lung transplantation is increasingly common with improving survival rates. Post-transplant patients can be expected to seek total hip (THA) and knee arthroplasty (TKA) to improve their quality of life. Outcomes of 20 primary total joint arthroplasties (15 THA, 5 TKA) in 14 patients with lung transplantation were reviewed. Clinical follow-up time averaged 27.5 and 42.8 months for THA and TKA respectively. Arthroplasty indications included osteonecrosis, osteoarthritis, and fracture. All patients subjectively reported good or excellent outcomes with a final average Harris Hip Score of 88.7, Knee Society objective and functional score of 92.0. There were 4 minor and 1 major acute perioperative complications. 1 late TKA infection was successfully treated with two-stage revision. The mortality rate was 28.5% (4/14 patients) at an average 20.6 months following but unrelated to arthroplasty. Overall, total joint arthroplasty can be safely performed and provide good functional outcomes in lung transplant recipients.

Food resource richness increases seed disperser visitations and seed rain richness.

Within the context of global change, seed dispersal research often focuses on changes in disperser communities (i.e., seed dispersers, such as birds, in an area) resulting from habitat fragmentation. This approach may not be completely illustrative due to certain seed disperser communities being more robust to fragmentation. Additionally, this top-down approach overlooks how changing food resources on landscapes impacts resource tracking and, subsequently, seed dispersal. We hypothesized resource tracking may promote diffuse plant-animal dispersal mutualisms if resource richness is positively linked to disperser and seed rain richness. We predicted increasing food resource richness attracts more visits and species of avian dispersers, resulting in higher counts and greater species richness of seeds deposited at sites (i.e., seed rain). We tested this mechanism in two replicated field experiments using a model system with bird feeders positioned above seed traps. In the first experiment, we demonstrated resource presence skews seed rain. In the second experiment, we explored how species richness of food resources (0, 4, 8, or 12 species) affected the species richness and visitation of avian seed dispersers at feeders and in subsequent seed rain. Collectively, we observed a positive relationship between available food resources and seed rain, likely mediated by resource tracking behavior of avian dispersers. Our findings underscore a potential key mechanism that may facilitate ecological diversity, whereby accumulating species richness in the plant community attracts a more diverse seed disperser community and indirectly promotes more species in seed rain. Importantly, the resource tracking mechanism driving this potential positive feedback loop may also result in negative ecosystem effects if global change diminishes resource availability through homogenization processes, such as invasive species colonization. Future research should explore the bottom-up effects of global change on food resources and seed disperser behavior to complement the literature on changing disperser communities.

The Spatial Ecology of Nuisance Crocodiles: Movement Patterns of Relocated American Crocodiles (Crocodylus acutus) in Guanacaste, Costa Rica.

Anthropogenic alterations of the environment have increased, highlighting the need for human-wildlife coexistence and conflict mitigation. Spatial ecology, and the use of passive satellite movement technology in particular, has been used to identify patterns in human-wildlife conflict as a function of shared resources that present potential for dangerous situations. Here, we aim to remotely identify patterns indicative of human-crocodile conflict in Guanacaste, Costa Rica by exploring site fidelity and diverse modes of movement (i.e., land and water) across space between nuisance (relocated) and non-nuisance (wild) crocodiles. Advanced satellite remote sensing technology provided near-constant movement data on individuals at the regional scale. Telonics Iridium SeaTrkr-4370-4 transmitters were used with modified crocodilian fitting. Results indicate that relocated crocodiles exhibited large-scale movements relative to wild crocodiles. Nuisance relocated crocodiles either returned to the area of nuisance or potentially attempted to in short time frames. The results presented here highlight the need for alternative management strategies that facilitate relocation efficacy.

Simultaneous vs staged bilateral total knee arthroplasty among Medicare beneficiaries, 2000-2009.

Simultaneous bilateral total knee arthroplasty (TKA) reportedly has higher postoperative complication rates than staged procedures, but little is known about recent trends and outcomes among Medicare patients. In a 5% national sample of Medicare beneficiaries older than 65 years, we identified 83,441 patients who underwent elective TKA between 2000 and 2009 and compared patients undergoing simultaneous bilateral TKA (n=4519) to staged TKA (n=3788). Use of simultaneous TKA did not change over time (3 in 10,000), but use of staged TKA increased three-fold from 1.4 to 4.4 in 10,000 person-years. We assessed length of stay; 5-year risk of revision; periprocedural (i.e., 90-day) risk of infection; hospitalization for venous thromboembolism (VTE) and myocardial infarction (MI); and death using Kaplan-Meier methods. Simultaneous TKA had higher 90-day risk of death (0.7% vs. 0.3%, P=0.02), VTE (0.9% vs. 0.5%, P=0.07), and MI (0.5% vs. 0.2%, P=0.02). Infection and revision rates were similar between the two groups.

Radiographic outcomes of ring external fixation for malunion and nonunion.

Ring external fixators such as the Ilizarov external fixator (IEF) and Taylor Spatial Frame (TSF) have revolutionized management of limb deformity. This study examines radiographic outcomes for treatment of malunions and nonunions with secondary emphasis on comparing radiographic union rates of TSF and IEF. A retrospective chart and radiograph review was performed. Fifty-four patients were included. Most injuries were in the tibia (96%). Fifty patients (93%) achieved radiographic union, two patients required further fixation, and two patients elected to undergo amputation. The preoperative coronal deformity improved from a mean of 12° (range, 0°-41°) to within 3° anatomic. Sagittal deformity improved from a mean of 11° (range, 0°-49°) to within 5° anatomic with some patients intentionally left in recurvatum to accommodate plantarflexion contractures. Limb length discrepancies were corrected to within 1 cm. Twenty-five patients experienced complications (mostly superficial pin tract infections). No statistically significant differences in the radiographic outcomes of TSF compared to IEF were identified.

The use of dual-mobility components in total hip arthroplasty.

Dual-mobility hip components provide for an additional articular surface, with the goal of improving range of motion, jump distance (ie, vertical or inferior head displacement required for dislocation), and stability of the total hip arthroplasty. A large polyethylene head articulates with a polished metal acetabular component, and an additional smaller metal head is snap-fit within the polyethylene. New components have recently been released for use in North America. Although these devices are routinely used in some European centers for primary hip arthroplasty, their greatest utility may be to manage recurrent dislocation in the setting of revision hip arthroplasty. Several small retrospective series have shown satisfactory results for this indication at short- to midterm follow-up. Polyethylene wear and intraprosthetic dislocation are concerns, as is the lack of long-term data. Caution is thus advised in the routine use of dual-mobility components in primary and revision total hip arthroplasty.

Computer-assisted reduction method for periprosthetic distal femur fracture.

The purpose of this case report is to describe a novel use of computer assistance in identifying and restoring the mechanical axis in the treatment of a periprosthetic distal femur fracture in a 76-year-old female patient with a total knee arthroplasty.

Citrobacter koseri as a cause of early periprosthetic infection after primary total hip arthroplasty.

Periprosthetic joint infection in the acute setting is usually caused by gram-positive species and remains a major problem facing total joint surgeons. We report a case of a 53-year-old male who presented with drainage 3 weeks after primary total hip arthroplasty. Citrobacter koseri was cultured from an infected hematoma in his deep tissues. Surgical treatment included irrigation and debridement with femoral head and liner exchange. He received a 6-week course of ertapenem and is currently asymptomatic. We present C. koseri as a rare cause of acute periprosthetic infection and offer an effective treatment protocol.

Gait symmetry: a comparison of hip resurfacing and jumbo head total hip arthroplasty patients.

Proponents of large femoral head total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) have touted the potential for restoration of more normal hip kinematics. This study examined 20 patients (10 THA and 10 HRA patients) approximately 18 months after surgery. Subjects were evaluated at a self-selected pace, while bilateral spatial-temporal gait variables, hip flexion/extension kinematics, and ground reaction forces were collected. For both groups, swing time was increased on the surgical side, whereas peak hip flexion, peak extension, and flexion at heel strike were decreased. Peak hip extension and peak vertical ground reaction forces were decreased in THA subjects compared with HRA subjects. After a large-diameter THA or HRA, subjects do not display symmetric gait approximately 18 months postoperatively. Total hip arthroplasty subjects demonstrated restricted hip extension and reduced limb loading when compared with HRA subjects.

Cost-effectiveness analysis of free vascularized fibular grafting for osteonecrosis of the femoral head.

Management of symptomatic pre-collapse osteonecrosis of the femoral head continues to be controversial. Patients are often young and active, therefore hip-preserving procedures such as free vascularized fibular grafting (FVFG) have been developed to relieve pain and restore function, thereby delaying or preventing the need for joint arthroplasty. This study compared the cost-effectiveness of FVFG to total hip arthroplasty (THA) in the young adult. A Markov decision model was created for a cost-utility analysis of FVFG compared to THA. Outcome probabilities and effectiveness, expressed in QALYs gained, were derived from existing literature. Principal outcome measures included average incremental costs, effectiveness, and net health benefits. Multivariate sensitivity analysis was used to validate the model. THA resulted in a greater average incremental cost (+$5,933) while at a lower average incremental effectiveness (-0.15 QALY) compared to FVFG. On average, THA gained 22.08 QALYs at a cost-effectiveness (C/E) ratio of $1026/QALY, whereas FVFG gained 22.23 QALYs at a C/E ratio of $752/QALY. Threshold sensitivity analysis determined that the yearly all-cause probability of revision for FVFG would have to be more than three times greater than THA before THA became more cost-effective. Free vascularized fibular grafting is a more cost-effective procedure to treat osteonecrosis in certain populations. Markov decision analysis accounts for the impact of treatment strategies over the lifetime of a patient cohort. These findings can inform clinical decision making in the absence of universally accepted management strategies.

Analysis of procedure-related costs and proposed benefits of using patient-specific approach in total knee arthroplasty.

Recently, patient-specific approaches to total knee arthroplasty (TKA) have been introduced that utilize preoperative magnetic resonance imaging data to manufacture custom cutting jigs specific to a patient's bony anatomy. These approaches intend to provide the benefits of accurate implant alignment while overcoming some of the proposed disadvantages of current computer navigation systems. In this study, a cost and benefit assessment of implementing the patient-specific approach compared to conventional and computer-navigated TKA was conducted at a large academic medical center. Fixed and time-dependent operating room (OR) costs were determined and compared, as well as the cost for processing operative equipment and additional procedure-related expenditures. Overall, patient-specific TKA was not cost saving in this model on a per-case basis compared to conventional methods, although it was less costly overall to the institution compared to implementing intraoperative navigation. However, the patient-specific approach provides the institution with an additional 28 minutes of available OR time per intervention based on reduction in preparation and operative times compared to conventional methods and an additional 67 minutes compared to computer navigation based on this model. This time savings is likely to provide a greater economic impact to the health care system than implant-related cost savings.

Case report: Neuropathic arthropathy of the hip as a sequela of undiagnosed tertiary syphilis.

BACKGROUND: Neuropathic arthropathy is characterized by rapidly progressive bone destruction in the setting of impaired nociceptive and proprioceptive innervation to the involved joint. It is seen most commonly in the foot and ankle, secondary to peripheral neuropathy in patients with diabetes mellitus. Other less common sites of involvement may include the knee, hip, shoulder, and spine, depending on the underlying etiology. Neuropathic arthropathy can be associated with tabes dorsalis, a unique manifestation of late, tertiary neurosyphilis that may arise in individuals with untreated syphilis many years after initial infection, and usually involves the knee, or less commonly, the hip. CASE REPORT: We report the case of a 73-year-old man with neuropathic arthropathy of the hip and tabes dorsalis attributable to previously undiagnosed tertiary syphilis. There was considerable delay in the diagnosis and unnecessary diagnostic testing owing to failure to consider syphilis as the cause. LITERATURE REVIEW: With the advent of effective antimicrobial therapy and public health campaigns, the relationship between untreated syphilis and neuropathic arthropathy has been primarily a historic point of interest. However, current epidemiologic research suggests a resurgence of syphilis in the United States, with an increased incidence of patients presenting with manifestations of tertiary syphilis from unidentified and untreated primary infections. Treatment options for neuropathic arthropathy of the hip are limited. Arthrodesis has had poor success and treatment with THA has had high complication rates. CONCLUSIONS: Syphilis is not merely a historic cause of neuropathic arthropathy. Neurosyphilis and tabes dorsalis should be considered in the differential diagnosis for patients presenting with rapid joint destruction consistent with Charcot arthropathy and no other apparent cause.

Fracture of highly cross-linked all-polyethylene patella after total knee arthroplasty.

Recent advances in polyethylene fabrication have led to the introduction of highly cross-linked polyethylene tibial and patellar components for use in total knee arthroplasty (TKA) with the goal of reducing wear-related osteolysis. However, some reports suggest decreased mechanical strength as a result of the additional thermal and sterilization treatments in the manufacturing of implants. Complications related to the patella are among the most common causes of failure in TKA, but patellar component fracture is rare. The authors report a case of a highly cross-linked all-polyethylene patellar component that failed as a result of fracture in vivo in a patient 3 years after TKA.