Simulation Training in Orthopaedic Surgery.

Simulation training encompasses all methods of learning technical skills that do not require practicing on a live patient. Surgical training typically uses an apprenticeship model, in which responsibility is gradually shifted from attending surgeon to the trainee over years of experiences with live patients. Skill acquisition from simulation modalities can prevent unnecessary harm to patients if trainees have practice and experience from simulation before participation in live surgeries. Surgeons are morally required to prevent unnecessary harm to patients, regardless of whether they are consequentialist or nonconsequentialist in one's metaethics. It is the authors' opinion that simulation training is a moral imperative, as there is early empirical evidence for preventing harm to patients and it should be incorporated to the extent it is feasible in every surgical training program. Further definitive studies need to be performed.

Issues in Ethics in Orthopaedic Surgery Following the COVID-19 Pandemic.

The COVID-19 pandemic has caused changes in health care as well as human suffering, and consideration of the principles of ethics can build a foundation to consider dilemmas that have arisen. Diversity, equity, and inclusion have become key issues. Simulation training and the related ethics of its application have taken on new meaning. Access to health care continues to evolve and will need further evaluation in the years following the COVID-19 pandemic.

Is a drought a drought in grasslands? Productivity responses to different types of drought.

Drought, defined as a marked deficiency of precipitation relative to normal, occurs as periods of below-average precipitation or complete failure of precipitation inputs, and can be limited to a single season or prolonged over multiple years. Grasslands are typically quite sensitive to drought, but there can be substantial variability in the magnitude of loss of ecosystem function. We hypothesized that differences in how drought occurs may contribute to this variability. In four native Great Plains grasslands (three C4- and one C3-dominated) spanning a ~ 500-mm precipitation gradient, we imposed drought for four consecutive years by (1) reducing each rainfall event by 66% during the growing season (chronic drought) or (2) completely excluding rainfall during a shorter portion of the growing season (intense drought). The drought treatments were similar in magnitude but differed in the following characteristics: event number, event size and length of dry periods. We observed consistent drought-induced reductions (28-37%) in aboveground net primary production (ANPP) only in the C4-dominated grasslands. In general, intense drought reduced ANPP more than chronic drought, with little evidence that drought duration altered this pattern. Conversely, belowground net primary production (BNPP) was reduced by drought in all grasslands (32-64%), with BNPP reductions greater in intense vs. chronic drought treatments in the most mesic grassland. We conclude that grassland productivity responses to drought did not strongly differ between these two types of drought, but when differences existed, intense drought consistently reduced function more than chronic drought.

Resolving the Dust Bowl paradox of grassland responses to extreme drought.

During the 1930s Dust Bowl drought in the central United States, species with the C3 photosynthetic pathway expanded throughout C4-dominated grasslands. This widespread increase in C3 grasses during a decade of low rainfall and high temperatures is inconsistent with well-known traits of C3 vs. C4 pathways. Indeed, water use efficiency is generally lower, and photosynthesis is more sensitive to high temperatures in C3 than C4 species, consistent with the predominant distribution of C3 grasslands in cooler environments and at higher latitudes globally. We experimentally imposed extreme drought for 4 y in mixed C3/C4 grasslands in Kansas and Wyoming and, similar to Dust Bowl observations, also documented three- to fivefold increases in C3/C4 biomass ratios. To explain these paradoxical responses, we first analyzed long-term climate records to show that under nominal conditions in the central United States, C4 grasses dominate where precipitation and air temperature are strongly related (warmest months are wettest months). In contrast, C3 grasses flourish where precipitation inputs are less strongly coupled to warm temperatures. We then show that during extreme drought years, precipitation-temperature relationships weaken, and the proportion of precipitation falling during cooler months increases. This shift in precipitation seasonality provides a mechanism for C3 grasses to respond positively to multiyear drought, resolving the Dust Bowl paradox. Grasslands are globally important biomes and increasingly vulnerable to direct effects of climate extremes. Our findings highlight how extreme drought can indirectly alter precipitation seasonality and shift ecosystem phenology, affecting function in ways not predictable from key traits of C3 and C4 species.

A reality check for climate change experiments: Do they reflect the real world?

Experiments are widely used in ecology, particularly for assessing global change impacts on ecosystem function. However, results from experiments often are inconsistent with observations made under natural conditions, suggesting the need for rigorous comparisons of experimental and observational studies. We conducted such a "reality check" for a grassland ecosystem by compiling results from nine independently conducted climate change experiments. Each experiment manipulated growing season precipitation (GSP) and measured responses in aboveground net primary production (ANPP). We compared results from experiments with long-term (33-yr) annual precipitation and ANPP records to ask if collectively (n = 44 experiment-years) experiments yielded estimates of ANPP, rain-use efficiency (RUE, grams per square meter ANPP per mm precipitation), and the relationship between GSP and ANPP comparable to observations. We found that mean ANPP and RUE from experiments did not deviate from observations. Experiments and observational data also yielded similar functional relationships between ANPP and GSP, but only within the range of historically observed GSP. Fewer experiments imposed extreme levels of GSP (outside the observed 33-yr record), but when these were included, they altered the GSP-ANPP relationship. This result underscores the need for more experiments imposing extreme precipitation levels to resolve how forecast changes in climate regimes will affect ecosystem function in the future.

Pushing precipitation to the extremes in distributed experiments: recommendations for simulating wet and dry years.

Intensification of the global hydrological cycle, ranging from larger individual precipitation events to more extreme multiyear droughts, has the potential to cause widespread alterations in ecosystem structure and function. With evidence that the incidence of extreme precipitation years (defined statistically from historical precipitation records) is increasing, there is a clear need to identify ecosystems that are most vulnerable to these changes and understand why some ecosystems are more sensitive to extremes than others. To date, opportunistic studies of naturally occurring extreme precipitation years, combined with results from a relatively small number of experiments, have provided limited mechanistic understanding of differences in ecosystem sensitivity, suggesting that new approaches are needed. Coordinated distributed experiments (CDEs) arrayed across multiple ecosystem types and focused on water can enhance our understanding of differential ecosystem sensitivity to precipitation extremes, but there are many design challenges to overcome (e.g., cost, comparability, standardization). Here, we evaluate contemporary experimental approaches for manipulating precipitation under field conditions to inform the design of 'Drought-Net', a relatively low-cost CDE that simulates extreme precipitation years. A common method for imposing both dry and wet years is to alter each ambient precipitation event. We endorse this approach for imposing extreme precipitation years because it simultaneously alters other precipitation characteristics (i.e., event size) consistent with natural precipitation patterns. However, we do not advocate applying identical treatment levels at all sites - a common approach to standardization in CDEs. This is because precipitation variability varies >fivefold globally resulting in a wide range of ecosystem-specific thresholds for defining extreme precipitation years. For CDEs focused on precipitation extremes, treatments should be based on each site's past climatic characteristics. This approach, though not often used by ecologists, allows ecological responses to be directly compared across disparate ecosystems and climates, facilitating process-level understanding of ecosystem sensitivity to precipitation extremes.

Differential sensitivity to regional-scale drought in six central US grasslands.

Terrestrial ecosystems often vary dramatically in their responses to drought, but the reasons for this are unclear. With climate change forecasts for more frequent and extensive drought in the future, a more complete understanding of the mechanisms that determine differential ecosystem sensitivity to drought is needed. In 2012, the Central US experienced the fourth largest drought in a century, with a regional-scale 40% reduction in growing season precipitation affecting ecosystems ranging from desert grassland to mesic tallgrass prairie. This provided an opportunity to assess ecosystem sensitivity to a drought of common magnitude in six native grasslands. We tested the prediction that drought sensitivity is inversely related to mean annual precipitation (MAP) by quantifying reductions in aboveground net primary production (ANPP). Long-term ANPP data available for each site (mean length = 16 years) were used as a baseline for calculating reductions in ANPP, and drought sensitivity was estimated as the reduction in ANPP per millimeter reduction in precipitation. Arid grasslands were the most sensitive to drought, but drought responses and sensitivity varied by more than twofold among the six grasslands, despite all sites experiencing 40% reductions in growing season precipitation. Although drought sensitivity generally decreased with increasing MAP as predicted, there was evidence that the identity and traits of the dominant species, as well as plant functional diversity, influenced sensitivity. A more comprehensive understanding of the mechanisms leading to differences in drought sensitivity will require multi-site manipulative experiments designed to assess both biotic and abiotic determinants of ecosystem sensitivity.

Applying fault tree analysis to the prevention of wrong-site surgery.

Wrong-site surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS and used the results to perform a fault tree analysis to assess the reliability of the system in preventing WSS and identifying high-priority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for WSS. The fault tree contains 35 faults, most of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing, and a brief time-out, a large proportion of the process relies on human transcription and verification. Fault tree analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process.

Orthopaedic expert opinion, testimony, and the physician as a defendant.

Medicolegal issues continue to challenge orthopaedic surgeons. Although health reform legislation has passed Congress, the first phase has not incorporated any significant changes regarding liability reform for practicing orthopaedic surgeons. Medical malpractice, personal injury, and workers' compensation litigation remains an issue for patients and physicians. Although orthopaedic surgeons can be defendants, it is more likely that they will be retained as treating physicians or experts as part of the litigation process. The involvement of a qualified physician as an expert witness is essential to the outcome of any litigation involving medical issues. As triers of the facts, the judge and jury members rely on quality medical testimony. Expert witness testimony can be a time-consuming process. A physician who assumes the role must be able to spend the time necessary to do a good job. A prepared expert witness can have a profound effect on litigation. A poorly prepared physician expert witness can be harmful to a case and risks the loss of prestige, honor among colleagues, and future work. Sanctions may be imposed by professional organizations. Most importantly, a physician working within the legal system must remain honest and tell nothing but the truth.

Nonsurgical treatment of closed mallet finger fractures.

PURPOSE: Surgical repair of closed mallet finger fractures has been favored for displaced injuries involving more than one third of the articular surface and for injuries with palmar subluxation of the distal phalanx. This study analyzed the results of nonsurgical treatment for closed and displaced mallet finger fractures with greater than one-third articular surface damage, comparing cases with and without concomitant terminal joint subluxation. METHODS: Twenty-two closed mallet finger fractures in 21 patients who were treated nonsurgically and involving more than one third of the articular surface were reviewed retrospectively. The patients were treated by continuous extension splinting of the distal interphalangeal joint for a mean of 5.5 weeks. The average patient age at the time of injury was 35.2 years, with a mean delay to treatment of 21 days. Nine cases showed a reduced distal interphalangeal joint at presentation (type IB) and 13 cases showed palmar subluxation of the distal phalanx (type IIB). Complications from splinting were limited to 2 cases of transient skin irritation. All patients returned for new finger radiographs and completed a survey to assess pain, function, and satisfaction at an average of 24.5 months after injury. RESULTS: Patients expressed negligible pain, minimal difficulties with activities of daily living and work, relatively high satisfaction with finger function and treatment outcome, but only marginal satisfaction with finger appearance. The differences between type IB and type IIB cases were not significant. The resultant terminal joint extensor lag improved in both groups. Moderate and large joint prominences, swan-neck deformities, and moderate arthritis were seen more commonly in type IIB cases but the differences between groups were not significant. CONCLUSIONS: This study supports the rationale for nonsurgical treatment of closed and displaced mallet finger fractures with greater than one-third articular surface involvement. Pain likely will be negligible and patient satisfaction with finger function and treatment outcome is projected to be relatively high at 2-year follow-up evaluation. A dorsal joint prominence, terminal joint extensor lag, swan-neck deformity, and degenerative joint changes, however, may develop, particularly in cases with palmar subluxation of the distal phalanx.