Accountable Operating Room Teams.

With Medicare reimbursement diminishing and the aging population consuming more health care, hospitals continue to push for reforms to improve the efficiency of health care delivery, decrease consumption, and elevate the quality of care. Operating rooms command a large share of hospital resources but are also major revenue generators. Surgical care has evolved to become more efficient and accountable. Defining the characteristics of an accountable operating room team has been more elusive and inconsistent. This review defines the characteristics of accountable operating room teams and recommends measures by which to evaluate them. [Orthopedics. 2021;44(4):e463-e470.].

Assessing knee anatomy using Makoplasty software a case series of 99 knees.

BACKGROUND: Role of MAKOplasty software in determining femoral neck version, distal-femoral resection angle, tibial axis difference, distal-femoral rotation, medial/lateral tibial slope, and tibial tubercle alignment has yet to be fully explored. METHODS: Preoperative CT scans and plain films of 99 patients were obtained for each patient according to predetermined MAKO-protocol by four observers. Reliability analyses (Cronbach's Alpha-test) was performed to determine agreement between raters for angle measures. RESULTS: Anatomic measurements were similar to previously published literature, and cronbachs'alpha analysis demonstrated agreement amidst all observers. CONCLUSION: MAKOplasty software produces similar results to anatomic measurements in planning for TKA with good reproducibility.

Interventions for Obesity and Nutritional Status in Arthroplasty Patients.

Nutritional risk in patients undergoing total joint arthroplasty has been well-studied with regard to diagnostic criteria; however, therapeutic management of abnormal body mass index (BMI) values and serum markers remains to be studied in patients undergoing joint replacement surgery. Patients with a BMI value of >40 kg/m2 are at increased risk for postoperative complications; weight loss programs and bariatric surgery are therapeutic modalities that can be used in the prehabilitation and long-term rehabilitation of patients undergoing total joint arthroplasty. Management of patients with abnormal nutritional status should be multidisciplinary and allow for the incorporation of dietitians and nutritionists in therapeutic planning. Hypoalbuminemia correction can be completed intravenously or orally; however, arthroplasty studies remain lacking with regard to the preferred modalities of correction.

Early Definitive Care Is as Effective as Staged Treatment Protocols for Open Ankle Fractures Caused by Rotational Mechanisms: A Retrospective Case-Control Study.

OBJECTIVES: To compare immediate internal fixation with primary wound closure to temporary fixation/stabilization with delayed fixation and wound closure protocols for management of open ankle fractures. DESIGN: Retrospective case-control study. SETTING: Level 1 trauma center. PATIENTS: Eighty-eight consecutive patients who presented with a Gustilo-Anderson type I, II, or IIIa open ankle fracture to a single center. INTERVENTION: Patients were divided into 2 cohorts: either immediate internal fixation with primary wound closure (EARLY) or temporary fixation/stabilization with delayed fixation and wound closure (STAGED) due to practice differences of the attending surgeons. MAIN OUTCOME MEASURES: Infection, length of stay, number and type of operations, and clinical measures. We also assessed the 2 groups with regard to demographics and radiographic classification. RESULTS: Overall, incidence of infection was 6 (6.8%) with no significant difference between patients treated with EARLY versus STAGED protocols. The EARLY cohort had a significantly shorter length of hospital stay, fewer number of reoperations but similar clinical outcomes for pain, ambulation, and radiographic evidence of osteoarthritis for patients followed for >12 months. CONCLUSION: Our study showed that early definitive treatment compared with a staged protocol for Gustilo-Anderson type I, II, and IIIa open ankle fractures has similar rates of infection, shorter hospital stay, fewer surgical interventions, and similar clinical outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of inherent tibial asymmetry on leg length discrepancy measurements after intramedullary nailing of comminuted femoral shaft fractures.

INTRODUCTION: Locked intramedullary nailing (IMN) is the standard treatment for femoral shaft fractures in adults with high rates of union and relatively low rates of complications. Leg length discrepancy (LLD) after IMN of femoral shaft fractures is common, and is reported in 20-43% of cases. A known surgical challenge when trying to obtain equal leg lengths is comminuted fracture, which results in a loss of bony landmarks that guide reduction. The purpose of this study was to assess the effect of inherent tibial asymmetry on LLD measurements after IMN. METHODS: Postoperative CT scanograms were performed on 79 consecutive patients after locked IMN for comminuted femoral shaft fracture. Leg lengths were determined by measurements taken from the scout view of a CT scanogram. Calculations of discrepancy were made for both femurs, tibias, and total leg length. Assessment was also made on the frequency wherein the tibial discrepancy compounded the femoral discrepancy. In situations where a limb segment was exactly symmetric to the contralateral side, the total leg was not regarded as a having compounded asymmetry. RESULTS: Notable discrepancies were found in tibial length that significantly departed from the null of symmetry (p < 0.0001). Forty-two patients (53.2%) were found to have a tibial asymmetry of 3 mm or more, and 20 patients (25.3%) were found to exhibit a difference of 6.3 mm or more. Median femoral discrepancy was 5.3 mm and median tibial discrepancy was 3.0 mm. Seven patients were found to be asymmetric in total leg length as a consequence of underlying tibial asymmetry. Conversely, 11 patients benefited from their tibial asymmetry, which compensated for femoral asymmetry after IMN. CONCLUSION: Tibial symmetry cannot be assumed. If not accounted for, inherent tibial asymmetry may influence LLD after IMN of femur fractures.

Review article: Current literature on surgical checklists and handoff tools and application for orthopaedic surgery.

Despite the adaptation of checklists for specific surgeries being developed, there remains a lack of an available standard for an orthopaedic-specific checklist. Benefits of implementing checklists include cost-effectiveness as well as the ability to significantly reduce both mortality and complication rates in a variety of healthcare settings. The aim of this review is to analyze the evidence surrounding the effectiveness of checklists as well as recommend for the development of a standard checklist for specific orthopaedic surgeries such as total joint arthroplasty (TJA).

Improving Total Joint Replacement with Continuous Quality Improvement Methods and Tools.

Faced with increasing pressure to reduce costs, hospitals must find new ways to eliminate waste while simultaneously maintaining the highest quality of care. For any institution, these can types of changes can be complex and burdensome. This article outlines several methods that have been successful in reducing costs while maintaining high quality and highlights feasible methodologies that can help health care providers implement new quality improvement protocols.

Professional Formation of Physicians Focused on Improving Care: How Do We Get There?

As the Accreditation Council for Graduate Medical Education (ACGME) and National Academy of Medicine (NAM) increase emphasis on quality improvement (QI), continuing medical education must also adapt to meet these increasing demands. In fellowship programs and for attending physicians, QI initiatives exist but are more rare compared with initiatives during residency programs, and they are even more rare for orthopedic surgery residents, fellows, and attending physicians. A QI curriculum should be in place at all stages of continuing medical education, as they help meet the criteria of the ACGME and NAM and promote better clinical practice and minimize errors.

Walk a Mile in the Leadership's Shoes: Why Focus on Quality Improvement?

Quality Improvement (QI) throughout health care in the United States continues to be of growing importance to both patients and providers. Leaders in health care including physicians, nurses, hospital administrators, and payors are all responsible for ensuring the continuation and growth of QI initiatives. This article will discuss various ways that healthcare leaders, with specific regard to orthopedic surgery, have utilized QI measures to provide better, more efficient, care to patients.