A Biomechanical Comparison of the Effect of Baseplate Design and Bone Marrow Fat Infiltration on Tibial Baseplate Pullout Strength.

BACKGROUND: Early clinical results of a new total knee arthroplasty (TKA) implant design show promise for improved outcomes and patellofemoral function scores. However, reports of early tibial component-cement interface debonding requiring revision have been published. This study investigated the biomechanical properties of three different tibial baseplates to understand potential causes of failure. METHODS: PFC Sigma (control), Attune (1st generation) and Attune S+ (2nd generation) tibial baseplates were implanted into 4th generation sawbone tibia models using a standardized technique. Three of each baseplate were cemented with and without additional bovine bone marrow fat. All models were tested to failure with measured axial distraction force. Implant type, presence or absence of bovine marrow and load to failure were all recorded and compared. Two-way ANOVA followed by post-hoc pairwise comparisons were used to determine statistical significance, which was set to P < .05. RESULTS: The 2nd generation tibial baseplates required significantly more force to failure. The presence of bovine marrow significantly reduced the pullout force of the implant designs overall. No significant difference was detected between the 1st generation and control baseplates. Failure mode for each model was also noted to be different irrespective of the presence or absence of bone marrow fat. CONCLUSION: The 2nd generation baseplates required significantly more force to failure compared with older designs. The presence of bone marrow during cementation of a tibial base plate significantly decreased axial pullout strength of a tibial baseplate in this laboratory model. All 1st generation baseplates exhibited debonding at the cement-implant interface.

Arthroscopic and Open or Mini-Open Rotator Cuff Repair Trends and Complication Rates Among American Board of Orthopaedic Surgeons Part II Examinees (2007-2017).

PURPOSE: To ascertain trends and reported complication rates of arthroscopic and open or mini-open rotator cuff repairs (RCRs) reported by American Board of Orthopaedic Surgery (ABOS) Part II examinees between 2007-2017. METHODS: The ABOS database was queried for both arthroscopic RCR (International Classification of Diseases code 29827) and open or mini-open RCR (International Classification of Diseases codes 23410 and 23412) performed by Part II examinees from 2007-2017. A comparison between overall procedure rates, as well as reported complications (anesthetic, medical, surgical, reoperations, and readmissions) associated with the respective repair technique, was performed. RESULTS: From 2007-2017, a total of 31,907 RCRs were reported by Part II examinees. Of those, 85.2% (n = 27,189) were arthroscopic whereas 14.8% (n = 4,718) were open or mini-open. The rate of arthroscopic RCR increased from 73% (n = 2,138) in 2007 to 90% (n = 2,031) in 2017, whereas the rate of open or mini-open RCR decreased from 27% (n = 771) to 10% (n = 234) during the same period. Rates of reported annual complications were significantly lower for arthroscopic RCR (7.4%-16.2%) than for open or mini-open RCR (12.9%-30.3%) for each of the past 6 years (2012-2017) (P < .001). Arthroscopic RCR had an overall lower cumulative occurrence of complications than open or mini-open RCR over the past decade (2007-2017) (P < .001). The relative risk of complications for arthroscopic RCR compared with open RCR was 0.71 (95% confidence interval, 0.66-0.77). CONCLUSIONS: ABOS Part II examinees reported an increased practice of arthroscopic RCR in comparison with open or mini-open RCR over the past 10 years. Reported annual complication rates have been significantly lower for arthroscopic RCR over the past 6 years, with an overall lower cumulative rate from 2007-2017. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Arthroscopic Versus Open Rotator Cuff Repair: Fellowship-Trained Orthopaedic Surgeons Prefer Arthroscopy and Self-Report a Lower Complication Rate.

PURPOSE: To evaluate whether fellowship training had an effect on the practice pattern and complication rates among Part II examinees of the American Board of Orthopaedic Surgery (ABOS) for rotator cuff repair (RCR) from 2007-2017. METHODS: The ABOS database was queried for arthroscopic (Current Procedural Terminology [CPT] code 29827) and open/mini-open (CPT codes: 23410, 23412) RCR performed from 2007-2017. Excluded were procedures that did not included CPT codes 29827, 23410, 23412. A comparison between arthroscopic and open/mini-open use as well as self-reported complications were assessed based on recorded fellowship training. RESULTS: A total of 31,907 RCR were reported over the past 10 years (2007-2017). The percentage of RCR procedures performed using arthroscopic technique vs open/mini-open varied among surgeons who completed one fellowship: Sports Medicine (92.5 % arthroscopy; 7.5 % mini/open), Shoulder & Elbow (91.3 % arthroscopy; 8.7% mini/open), and Hand & Upper Extremity (69.6 % arthroscopy; 30.4 % open). Total complication rates varied among surgeons who completed one fellowship: Sports Medicine (11.5 %), Shoulder & Elbow (13.5 %), and Hand & Upper Extremity (13.4 %). Surgeons completing one fellowship in either Sports Medicine, Shoulder & Elbow, Hand & Upper Extremity all reported significantly lower complication rates using arthroscopic over mini/open technique (P < .001). CONCLUSIONS: Among ABOS Part II examinees completing a Sports Medicine, Shoulder and Elbow or Hand and Upper Extremity fellowship, Sports Medicine trained surgeons had significantly greater rates of performing arthroscopic over open RCR and significantly lower self-reported intraoperative complication rates. CLINICAL RELEVANCE: Understanding the effects of fellowship training may guide mentors and future trainees.

Capnocytophaga canimorsus Periprosthetic Joint Infection in an Immunocompetent Patient: A Case Report.

INTRODUCTION: A periprosthetic joint infection (PJI) is a potentially devastating complication following an arthroplasty procedure. There are many organisms that commonly cause this complication; in this case report, we will discuss a PJI caused by an unusual bacteria found in the mouths of domestic pets. OBJECTIVE: To present a case report of a patient with a periprosthetic hip infection from Capnocytophaga canimorsus and review the literature. METHODS: We present a case of C canimorsus PJI in an immunocompetent woman who had undergone a total hip arthroplasty. The patient was doing well postoperatively for many years until she was bitten on the foot by a domestic canine. Patient diagnosed using Musculoskeletal Infection Society criteria, then treated with explant of the hip prosthesis, irrigation and debridement, placement of an antibiotic cement spacer, and a 6-week course of intravenous antibiotics. RESULTS: Unfortunately, while awaiting replant, this patient had a massive myocardial infarction and died. DISCUSSION: Current literature suggests treating canine bites with amoxicillinas well as a discussion with patients pre-/postoperatively from a lower extremity arthroplasty specialist. CONCLUSION: Capnocytophaga canimorsus is a rare cause of infection, even more unusual in an immunocompetent patient. This study highlights the importance of considering C canimorsus as a cause of PJI, regardless of the immunologic status of the patient.

Splenic trauma in the pediatric patient: the integrated roles of ultrasound and computed tomography.

Seven children who sustained splenic trauma were scanned by ultrasound and computed tomography (CT) or ultrasound and nuclear liver/spleen scan. All patients were managed conservatively and did not need abdominal surgery. On the initial sonogram, the majority of children had multiple areas of both increased and decreased echogenicity. Hematomas were followed to resolution in five of seven children and were usually multiple and hypoechoic prior to complete disappearance. On contrast-enhanced CT scans, areas of splenic hemorrhage appeared as low attenuation. Our small patient population demonstrates that, following an initial CT scan, sonography is helpful for sequential splenic imaging to show when the appearance of the spleen returns to normal. When correlated with the clinical information, such data are helpful to the clinician in determining when a child who has sustained splenic trauma may resume normal activity.

Objectively evaluating student case presentations.

Evaluation and documentation of student performance is of major importance to a radiology elective coordinator. To better assess a variety of aspects of competence and learning, an oral case presentation was included in the final elective evaluation. This article describes the 31-item checklist designed to assess the level of student achievement of the objectives for the oral presentation. In addition to developing this standard evaluation instrument, methodologies were used to increase the validity and reliability of the oral presentation; the examiners were briefed in advance, the checklist included cognitive and noncognitive measures, and a simple grading score was used for each item. Students who received the checklist and written course objectives at the beginning of the elective earned better grades than those students who did not receive the materials. Student evaluations reveal that the oral case presentation as presently organized is felt to be of value.

Constructing pre- and post-tests in a medical student elective.

The importance of evaluating medical student performance has been widely addressed in the medical education literature. Multiple-choice examinations are the preferred method of testing because they are easy to administer and score. Development of parallel or equivalent pre- and post-examinations provides objective information regarding actual knowledge gains by the students during the elective and points to strengths and weaknesses in the elective. This article provides information for developing the parallel multiple-choice questions for effective pre- and post-tests.

Guidelines for writing multiple-choice questions in radiology courses.

Objective evaluation of students frequently includes the utilization of multiple-choice test questions. Due to constraints on faculty time, however, the writing of these questions is usually completed quickly and somewhat haphazardly. The guidelines contained in this article were written to help radiologists produce better test questions for the purpose of improving the evaluation of clerkship students. The guidelines include choosing an item that is worth testing and has one definite answer, asking a single, clearly formulated question, avoiding true-false stems, being concise when writing the question, avoiding the use of negatives in the stem, avoiding using "all of the above" or "none of the above" as a response, avoiding subtle clues toward the keyed answer or away from the distractors, avoiding one-word definitions as responses, and placing the responses in logical or numerical order. A definition of terms used in the educational literature and a discussion of a quantitative evaluation of test questions are included.

First-year medical students' attitudes toward radiology.

To explore the perspectives of entering medical students, a questionnaire was completed anonymously by 171 students in September of their first year of medical school. The authors investigated their attitudes toward radiology relative to other specialties and their perspective concerning which factors would influence their eventual choice of a specialty. Upon entering medical school, 33.3% of the students indicated that they had chosen a specialty, and 7.4% of these students had selected radiology. Radiology was perceived as a well-paid specialty with a pleasant lifestyle. These are factors that were perceived as very important regarding influence on eventual choice of specialty. However, radiology was believed to have an undesirably low level of patient contact and was perceived as not being intellectually exciting. We plan to follow this group of students prospectively through medical school to see whether their attitudes change toward radiology as a career.

Systematic evaluation and increased structure in a radiology elective.

Diagnostic radiology is expanding, playing an increasingly central role in patient care, which heightens the importance of radiology teaching in undergraduate medical education. This study examined the impact of increased structure and systematic evaluation on student performance in a radiology elective. The evaluation protocol included premultiple and postmultiple choice examinations (70 questions each), a film interpretation quiz (ten films, 20 questions), faculty assessment of a student oral case presentation, and student evaluations of the elective experience. The relationships among the evaluation techniques, as well as differences in class level and course ratings were also examined. Two different treatment groups were studied. Group 1 was given general objectives and information regarding availability of recommended resources, including self-learning materials for the elective, didactic seminars, and viewbox exposure. Group 2 was given specific written instructional objectives, a structured schedule for viewing the self-learning materials, and the same seminars and viewbox exposure. The statistically significant higher performance of the structured group suggests that medical students achieve the objectives of an elective better when learning activities are well defined, structured, and systematically evaluated. In addition, those students receiving the structured experience rated the radiology elective more favorably.

Journal publications in radiology education. A review of the literature, 1966-1986.

Published scholarly activity pertaining to radiology education is relatively uncommon compared with an extensive clinical literature. To guide future radiology educational efforts in a time of changing priorities and practice patterns, the authors undertook an in-depth review and analysis of the existing radiology education literature covering the 20-year period from 1966 to 1986. A total of 194 articles was identified via a computerized literature search and manual cross-checking of cited references. Articles pertinent to medical student radiology education (36.6%) or radiology resident education (29.9%) predominated. The majority of published radiology education articles were editorials (35.5%) or expository in nature (49.5%). Surveys (5.1%) and experimental research (8.7%) comprised the balance. Although editorial opinions and personal reflections are important and valuable resources for radiology educators, a substantial lack of empirical research in radiology education exists. Additional knowledge in underdeveloped research areas is essential for future curriculum planning and development in radiology education.

Medical student attitudes toward radiology. A multi-institutional survey.

A questionnaire was administered to 238 students at four institutions before and after a radiology clerkship to evaluate student attitudes regarding radiology as a career, radiologist expertise, and clerkship expectations. There was no statistically significant difference among the clerkships, although they varied in types of experience, geographic location, and size. After the clerkship, the students agreed more strongly that the radiologist should be involved in patient workup, screening of requests, interpretation of emergency room films, and consultations. A significant change in attitude could be identified after the four-week experience, indicating a desire for the radiologist to have a more active role as imaging consultant.

A multifaceted approach to changing handwashing behavior.

BACKGROUND: Few interventions to influence handwashing have had measurable effects. This prospective quasi-experimental study was designed to address predisposing, enabling, and reinforcing factors to improve frequency of handwashing. METHODS: Over a 12-month time period, a multifaceted intervention including focus group sessions, installation of automated sinks, and feedback to staff on handwashing frequency was implemented in one intensive care unit; a second unit served as a control. Dependent variables observed were handwashing frequency and self-reported practices and opinions about handwashing. Study phases included baseline, three phases of about 2 months each in duration in which sink automation was incrementally increased, and follow-up 2 months after intervention. RESULTS: During 301 hours of observation, 2624 handwashings were recorded. Proportion of times hands were washed varied by indication, ranging from 38% before invasive procedures to 86% for dirty-to-clean procedures (p < 0.00001). Although there were some significant differences between experimental and control units in handwashing during the study, these differences had returned to baseline by the 2-month follow-up. There were no significant differences in self-reported practices and opinions from before to after intervention nor between units. CONCLUSIONS: Intensive intervention, including feedback, education, and increased sink automation, had minimal long-term effect on handwashing frequency.

Assessment of urine collection technique for microbial culture.

Two methods of urine collection-clean catch and midstream only-were compared in 200 samples (100 with each technique). There were no significant differences between the two collection methods with regard to number of positive culture results or types and counts of organisms isolated. There is little if any added benefit to special preparation for urine collection for culture.

Late results of fundoplication for gastroesophageal reflux in infants and children.

The Nissen fundoplication (NFP) for the management of severe gastroesophageal reflux (GER) in infants and children has become one of the most frequently performed operations in pediatric surgical centers in the United States. Short-term outcome, morbidity, and mortality are consistently favorable in several large series. The long-term success of this procedure is presumed but has not been established objectively. To examine the late results of this operation, 46 infants and children were carefully evaluated more than 5 years after NFP (mean, 6.7 years). Evaluation included parental interview, physical examination, upper gastrointestinal series, and esophageal pH monitoring. The mean age at the time of operation was 4.13 years. Fifty-seven percent of the patients had significant neurologic impairment, and 80% had at least one serious additional medical problem. Twenty-four percent of the children died during the period of follow-up--all but one death related to serious underlying medical problems. Of the 35 survivors, 26 (74.3%) have no symptoms; five (14.3%) have mild symptoms potentially referable to GER that necessitate little if any treatment; four (11.5%) have had symptomatic recurrence of GER necessitating repeat fundoplication. Three of these patients now have no symptoms. Forty-five percent of the patients had at least one postoperative complication. NFP provides efficacious, long-term treatment of GER in infants and children, with acceptable morbidity. Mortality in this group of children is related primarily to associated diseases rather than to GER.

Periventricular cavitations in the first week of life.

Eleven infants were encountered (nine premature, two term) in whom well-defined small periventricular cavitations were found by sonography in the first week of life. The sonographic findings bore remarkable similarity to subependymal pseudocysts in neonates previously described in autopsy specimens. The cavitations, which were identified predominantly along the superolateral aspects of the lateral ventricles, did not evolve in the manner of postnatally acquired periventricular leukomalacia. The location of the cavitations differed from the site of previously reported lesions of posthemorrhagic and postinfectious germinolysis along the medial aspect of the caudothalamic groove. Neurosonologists and neonatologists should be alerted to this finding and encouraged to follow these infants as a separate group to learn whether neurodevelopmental sequelae occur in these children.

Predicting outcome at the knee in juvenile rheumatoid arthritis.

This study was undertaken to correlate long-term severe radiographic changes with clinical profiles in an attempt to identify a group of patients at risk. Knee radiographs of 100 juvenile rheumatoid arthritis (JRA) patients with 1-20 years of follow-up studies were reviewed for changes leading to severe disability. Eighteen children had evidence of destructive changes an average of 4.3 years after onset of JRA. 23 patients had reactive changes superimposed on destructive changes seen 9.7 years after onset of disease. 92% of the children with reactive and destructive knee changes had radiographic evidence of significant JRA at another joint. Polyarticular disease with significant JRA involvement of another joint seems to indicate a group of children at higher risk for destructive and reactive changes at the knee.

Familial cervical dysplasia.

Nine of twelve family members from three generations were affected by an inherited form of cervical vertebral dysplasia. All of the affected people had an abnormality of the first cervical vertebra. Some also had defects of the axis and caudad to it. The mode of transmission of the disorder is autosomal dominant, with apparently complete penetrance and variable expressivity. Two patients had symptoms. One had a passively correctable tilt of the head, with an associated audible clunk and hypoplasia of the left superior facet of the second cervical vertebra. This patient had no local symptoms, neurological involvement, or muscle spasm. In the other patient, suboccipital pain developed. Radiographs revealed an anterior atlanto-occipital dislocation. The symptoms resolved after reduction and arthrodesis. Because of the apparently complete penetrance of this disorder, physicians caring for patients who have this type of congenital malformation of the cervical spine should consider examination of closely related members of the family. Clinical findings such as tilting of the head, torticollis, or limitation of cervical motion suggest that additional evaluation should be done. The examination should include lateral radiographs of the cervical spine in flexion and extension. Three-dimensional computed-tomography reformatting was helpful in demonstrating the complex cervical anatomy in our patients. Patients who have recognized abnormalities should be followed and should be re-examined whenever local or neurological symptoms develop. A magnetic resonance image of the spine in flexion and extension was valuable for identification of the potentially disastrous situation of impending damage to the cord in patients who had instability and evolving symptoms.

Limitations of student evaluations of curriculum.

RATIONALE AND OBJECTIVES: Medical student surveys are used extensively in the development and modification of curriculum. The purpose of this study was to look at medical student surveys of a radiology lecture series, evaluating the accuracy of student perceptions of learning and factors affecting them. MATERIALS AND METHODS: After a "Case of the Week" lecture series, 156 3rd-year medical students returned a survey evaluating the experience with 10 questions on a four-point scale (1 = disagree, 4 = agree very much) and took a clinical competency assessment (CCA) examination with a radiology substation. Survey responses were compared with actual examination performance, analyzed for how overall learning was characterized in specific educational objectives, and evaluated for factors affecting perceived learning. RESULTS: The mean response for perceived CCA examination preparedness was 1.83. The mean radiology station test score was 90.43%. Correlations between student perception of learning and the scoring of focused learning objectives ranged from 0.33 to 0.48 (P < .01). Students responding 1 to items assessing perceived lecture organization, stimulation to read, and interest in the field of radiology had mean scores for perception of overall learning of 2.09-2.44 and mean scores for recommendation of course continuation of 1.68-2.46. Students responding 4 had means of 3.25-3.81 and 3.06-4.0, respectively. CONCLUSION: Student perceptions of the value of curriculum were inaccurate compared with external measures of performance, and students poorly related their general impressions to specific learning objectives. Perceived lecture organization, stimulation to read, and interest in radiology as a specialty affected perceived overall learning and perceived value of the lecture series.

Improvement of faculty teaching performance: efficacy of resident evaluations.

RATIONALE AND OBJECTIVES: We assessed the effects on the perceived quality of faculty teaching of a resident evaluation form that solicits specific comments on faculty strengths and weaknesses. METHODS: An evaluation form was devised that rated faculty on a scale of 1-10 in teaching conference quality, availability, efficiency, and teaching. The form requested constructive comments on faculty strengths and weaknesses. The forms were completed anonymously by residents at all levels. Individual results and means for the department were tabulated and provided to each faculty member in a personal interview. Change in performance was assessed by comparing faculty evaluation scores for 2 consecutive years. RESULTS: The mean faculty scores for teaching conference quality, availability, efficiency, and teaching increased from 7.8, 7.9, 7.9, and 7.7 to 8.1, 8.3, 8.3, and 8.1 in each of the respective areas. The scores of the faculty members who initially received the 10 lowest scores rose to an even greater extent (from 6.2, 6.2, 6.0, and 6.0 to 6.8, 7.4, 7.3, and 6.8 in each of the respective areas), whereas the scores of the faculty members who initially received the 10 highest scores remained relatively constant. CONCLUSION: The perceived quality of certain focused aspects of resident teaching can be modified by use of resident evaluations that solicit specific suggestions for improvement. With appropriate feedback, this is an effective tool for improving the teaching performance of radiology department faculty, particularly those considered to be the weakest teachers.