Maximizing function and outcomes in acetabular reconstruction: segmental bony defects and pelvic discontinuity.

Acetabular reconstruction in revision total hip arthroplasty can be complicated by acetabular bone loss. In patients with severe acetabular bone deficiency with segmental bone defects or pelvic discontinuity, obtaining a stable, well-fixed acetabular component can be challenging. Although porous-coated, uncemented hemispheric cups can be used in most acetabular revisions, as the severity of acetabular deficiency increases, more complex alternatives are needed. Antiprotrusio cages have traditionally been used in the presence of acetabular columnar deficits, but higher failure rates and complications necessitated the development of alternative treatments. More recently, porous-coated acetabular augments have become an attractive alternative to structural allograft and oblong components when segmental bone loss is present. In the setting of severe bone loss or pelvic discontinuity, multiple reconstructive options are available. Depending on individual patient characteristics, plating of the pelvic discontinuity along with structural allografts, custom components, and modular or standard reconstructive cages can be used to obtain a stable acetabular component.

Advances in acetabular reconstruction in revision total hip arthroplasty: maximizing function and outcomes after treatment of periacetabular osteolysis around the well-fixed shell.

As the incidence of primary and revision hip arthroplasty increases, the need for a comprehensive approach to acetabular revision cannot be overstated. In the presence of osteolysis, there is a substantial population of patients with a well-fixed acetabular shell. It will be helpful to orthopaedic surgeons to review the classification of acetabular defects, techniques for exposing an acetabular component when the femoral component will be retained, methods of facilitating access to osteolytic lesions, the principles of bone grafting, options for liner fixation, and when removal of a well-fixed shell is necessary.

Acetabular reconstruction in revision total hip arthroplasty: maximizing function and outcomes in protrusio and cavitary defects.

Osteolysis in the periacetabular region is a common long-term complication of total hip arthroplasty that can lead to bone loss, implant loosening, and protrusio. Several systems have been developed for classifying osteolysis and guiding treatment. Options such as bone grafting or augmentation, with exchange of the bearing surface and, in some cases, revision of the acetabular component, can be used for treatment. Most cavitary and protrusio defects can be treated with a cementless revision cup using screw fixation and grafting with morcellized bone. However, structural augmentation, custom components, or cage reconstruction may occasionally be necessary for managing larger defects with severe loss of acetabular bone stock.

Overcoming resistance to implementation of integrated care pathways in orthopaedics.

The future of orthopaedic surgery will be shaped by unprecedented demographic and economic challenges, necessitating movement to so-called "second curve" innovations in the delivery of care. Implementation of integrated care pathways (ICPs) may be one solution to imminent cost and access pressures facing orthopaedic patients in this era of health-care accountability and reform. ICPs can lower costs and the duration of hospital stay while facilitating better outcomes through enhanced interspecialty communication. As with any innovation at the crossroads of paradigm change, implementation of integrated care pathways for orthopaedics may elicit surgeons' concern on a variety of grounds and on levels ranging from casual questioning to vehement opposition. No single method is always effective in promoting cooperation and adoption, so a combination of strategies offers the best chance of success. With a special focus on total joint replacement, we consider general patterns of resistance to change, styles of conflict, and specific issues that may underlie orthopaedic surgeon resistance to implementation of integrated care pathways. Methods to facilitate and sustain orthopaedic surgeon engagement in implementation of such pathways are discussed.

Patient demographics and risk factors in pediatric distal humeral supracondylar fractures.

The literature on distal humeral supracondylar fractures does not systematically define relationships between patient characteristics and the severity or complications of these injuries. This study evaluated age, sex, height, and body mass index (BMI) in relation to fracture severity and posttreatment complications in a pediatric population. The medical records of 382 pediatric patients treated for distal humeral supracondylar fractures over a 5-year period at 1 institution were included. Variables included age, sex, height, weight, injury mechanism, fracture severity (Gartland Classification), treatment, follow-up duration, and treatment complications. Body mass index and BMI-for-age percentile were calculated. Descriptive statistics with univariate analyses and logistic regression analysis with odds ratios and 95% confidence intervals were used. Children sustaining Gartland type 3 fractures were significantly older and taller than those sustaining Gartland type 1 and 2 fractures. No significant difference existed in fracture occurrence between boys and girls. Fracture severity did not differ significantly due to sex, BMI, or BMI-for-age percentile. Severe fractures were associated with increased posttreatment complications. Complication rates did not vary significantly by age, sex, height, BMI, or BMI-for-age. Taller children aged 5 to 6 years were at the greatest risk for Gartland type 3 distal humeral supracondylar fractures. Severe fractures are associated with an increased complication risk. Sex, BMI, and BMI-for-age percentile had no effect on fracture severity or complication rates.

Quality in orthopaedic surgery--an international perspective: AOA critical issues.

Quality is a hallmark of health care, although it is difficult to come to a consensus on who gets to define what "quality health care" is. Most health-care workers enter this field with the goal of improving the health of their patients (and the community), and while everyone tries to do the best job possible, we must continuously seek better methods and techniques for achieving better outcomes. The passion for continuous improvement is fundamental, but passion is not sufficient by itself. There is substantial opportunity to improve quality and reduce cost in health care. Multidisciplinary teams that include physicians, nurses, and other ancillary care providers have led to decreased waiting times to see specialists and have also led to better management of chronic disease. By including ancillary care, providers can increase cancer-screening rates and have the potential to decrease readmissions. Moreover, the addition of hospitalists and physician assistants can produce quality and efficiency outcomes that are commensurate with those enjoyed by traditional house staff. However, truly improving performance is difficult due to questions about how we define "quality," design care processes, measure inputs and outputs, develop multi-stakeholder collaborations, and develop incentive programs for delivering "good" care. There is a definite need for more thorough and robust studies of the impact of pay-for-performance programs, with the inclusion of ancillary care providers. Current research has not shown that there is not enough evidence to be able to determine what incentive structure might "work" in a particular health-care system. Payment systems will continue to evolve to incentivize greater collaboration among providers to yield higher-quality, lower-cost care. Future efforts will necessitate the need for strong physician leadership in helping to develop an optimal care team that is as patient-centered as possible. Technology adds dimensions of capability to making improvement real and systematic, as well as providing safer care with fewer errors and better adherence to proven best practices. The drive for quality with technology produces better clinical outcomes and maximizes efficiencies and financial metrics of organizational performance. Technology also adds capabilities for capturing key metrics and reporting them back to clinicians and others. Improved data transparency informs those who can actually do things differently to produce better results and outcomes. While health-care entities strive to focus on quality of care, measuring and reporting such care in a meaningful way are difficult. The best chance of improving overall care for patients is through the adoption of systems that improve coordination and continuity, not by health-care staff working harder. Only through collaboration and integration can health care incorporate a culture for improving quality and patient safety.

Effect of social media in health care and orthopedic surgery.

With the growth of social media platforms, their potential to affect health care, and orthopedics specifically, continues to expand. We reviewed the literature to obtain all pertinent information on social media in health care and examined its strengths and weaknesses from patient and physician perspectives. Health care professionals have slowly begun to use social media to stay connected with patients. The recent use of networking sites aims to improve education, provide a forum to discuss relevant medical topics, and allow for improved patient care. The use of social media, with the understanding of its limitations, may help promote patient happiness and safety and serve as an educational platform.

Redefining revision total hip arthroplasty based on hospital admission status.

This study examined patient demographics, length of hospital stay, and discharge disposition in those undergoing nonelective revision total hip arthroplasty (rTHA) vs elective rTHA. Data from 23 000 patients with hip revisions from 2005 through 2007 were extracted from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database. We examined patient admission status, demographics, length of stay, and discharge location. We found that patients undergoing nonelective rTHA were older, were female, had more comorbidities, stayed an excess of 1.61 days in the hospital, and required a skilled care facility after discharge compared with those undergoing elective rTHA. We found that rTHA outcomes varied based on patient hospital admission status. Patients who elected to have rTHA had less comorbidities, cost, and likelihood of being discharged into a skilled care facility.

Occupational hazards to the pregnant orthopaedic surgeon.

The number of female orthopaedic residents and orthopaedic surgeons has increased substantially. Concerns have been raised regarding the effect of the work environment on the health of the female orthopaedic surgeon and her fetus or neonate. Occupational risks, and specifically risks to the pregnant orthopaedic surgeon, are becoming an important issue in medicine. Such risks include exposure to methylmethacrylate (MMA), anesthetic gases, blood-borne pathogens, radiation, emotional stress, and physical stress. Awareness of and knowledge about such exposures are needed for the pregnant orthopaedic surgeon to make informed decisions about her occupational exposures and to be proactive about her own and her child's health.

The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability.

Disruptive physician behavior imperils patient safety, erodes the morale of other health care providers, and dramatically increases the risk of malpractice litigation. Increasing patient volume, decreasing physician reimbursement, malpractice litigation, elevated stress, and growing job dissatisfaction have been implicated in disruptive behavior, which has emerged as one of the major challenges in health care. Because the aging patient population relies increasingly on orthopaedic services to maintain quality of life, improving professionalism and eradicating disruptive behavior are urgent concerns in orthopaedic surgery. Although many steps have been taken by The Joint Commission to improve patient care and define disruptive behavior, there is further room for improvement by physicians. Barriers to eliminating disruptive behavior by orthopaedic surgeons include fear of retaliation, lack of awareness among the surgeon's peers, and financial factors. Surgeons have a duty to address patterns of negative peer behavior for the benefit of patient care. This manuscript addresses the causes and consequences of disruptive physician behavior as well as management strategies, especially in orthopaedic surgery.