Oleg Safir

Acetabular revision using an anti-protrusion (ilio-ischial) cage and trabecular metal acetabular component for severe acetabular bone loss associated with pelvic discontinuity

Pelvic discontinuity with associated bone loss is a complex challenge in acetabular revision surgery. Reconstruction using ilio-ischial cages combined with trabecular metal acetabular components and morsellised bone (the component-cage technique) is a relatively new method of treatment. We reviewed a consecutive series of 26 cases of acetabular revision reconstructions in 24 patients with pelvic discontinuity who had been treated by the component-cage technique. The mean follow-up was 44.6 months (24 to 68). Failure was defined as migration of a component of > 5 mm. In 23 hips (88.5%) there was no clinical or radiological evidence of loosening at the last follow-up. The mean Harris hip score improved significantly from 46.6 points (29.5 to 68.5) to 76.6 points (55.5 to 92.0) at two years (p < 0.001). In three hips (11.5%) the construct had migrated at one year after operation. The complications included two dislocations, one infection and one partial palsy of the peroneal nerve. Our findings indicate that treatment of pelvic discontinuity using the component-cage construct is a reliable option.

Management of bone loss: structural grafts in revision total knee arthroplasty.

Massive bone defects are challenging problems in revision knee surgery. When defects are large and uncontained (without a cortical rim), structural allografts may be used to provide support for femoral and tibial components. This study reviewed 68 structural allografts at a mean of 5.4 years for clinical and radiographic outcomes. Indications for grafts included periprosthetic fracture in 19 knees, aseptic loosening in 29, infection in 11 and instability in 2. Seven knees had both femoral and tibial allografts. Multiple implant designs were used including 7 hinged prostheses. Thirteen knees (13/61) failed due to graft related complications including one graft nonunion, three aseptic loosenings, three periprosthetic fractures, four infections, and two for instability. The case of graft nonunion was successfully treated with revision fixation and autologous bone graft. There were three cases of graft resorption, two graded as severe and one as moderate. These results are satisfactory given the nature and complexity of the problem, however, reconstructive procedures require careful preoperative preparation and extensive experience in complex knee arthroplasty.Level of Evidence: Therapeutic study, level IV (case series). See Guidelines for Authors for a complete description of levels of evidence.

How effective is self-guided learning of clinical technical skills? It's all about process

Objectives  Mounting evidence suggests that trainees acquire psychomotor skills better when they are allowed self‐guided access to instructional material and when they set goals that are related to performance processes rather than performance outcomes. The present study assessed whether self‐guided access to instruction and the setting of process goals lead to better acquisition of clinical technical skills.

Orthopedic boot camp: examining the effectiveness of an intensive surgical skills course.

BACKGROUND Changes in health care across the globe have had a profound impact on the number of hands-on surgical training opportunities that are available to residents. In the current study, we examine whether an intensive laboratory-based skills course at the start of orthopedic surgical training is an effective mechanism for teaching core technical skills. METHODS First-year residents were divided into 3 groups (on-service, n = 8; off-service, n = 8; and a new, competency-based program that has as a major element of the curriculum a focused, intensive skills laboratory-based experience, n = 6). Baseline surgical skills were assessed prior to commencing training. The intensive skills laboratory group was then given an intensive surgical skills course, whereas the other 2 groups embarked on traditional residency. After the surgical skills course, all the residents were assessed for core surgical skills using an objective structured assessment of technical skills (OSATS) procedure. RESULTS Pretraining scores revealed no differences between the groups of residents using both checklist (F[2,19] = 0.852, P = .442) and global rating scores (F[2,19] = 0.704, P = .507). Post-training scores revealed a significant difference, with residents from the intensive skills laboratory group performing better on both the checklists (on-service = 78.9, off-service = 78.6, intensive skills laboratory = 92.3; F[2,19] = 6.914, P < .01) and global rating scores (on-service = 3.4, off-service = 3.4, intensive skills laboratory = 4.3; F[2,19] = 5.722, P < .01), than the other groups who showed no differences between them. CONCLUSION The intensive skills course used in this study was highly effective at teaching and developing targeted surgical skills in first-year orthopedic residents. We predict that allowing residents to acquire key technical skills at the start of their training will enhance learning opportunities at later stages of training.

Three-Year Experience with an Innovative, Modular Competency-Based Curriculum for Orthopaedic Training

In response to multiple stresses in current surgical education, we developed a new model of orthopaedic training that combines curricular reform with a competency-based framework. For the past three years, this pilot program has been run in parallel to our conventional curriculum for a select number of residents. In this article, we share our initial experience with this approach to training and describe its successes and challenges. We review the existing concerns with surgical training in a new era of work-hour restrictions and describe the pedagogical rationale for the model that we have developed. We then discuss the design of this curriculum, including the basic tenets and principles that guided our approach. Finally, we detail our preliminary results, which add evidence that a focused, modular-based program, with concentrated teaching of technical skills and frequent formative and summative evaluations, can result in rapid acceleration in surgical competency, knowledge acquisition, and comprehensive professional skills. This new model deserves further study and consideration for implementation on a broader scale in today’s challenging medical education environment. There have been questions about our general approach to surgical education for quite some time. Charles Bosk catalogued some of the good and much of the bad that went along with residency education a quarter of a century ago1. Similarly, William Nolan2 described the rigors of surgical training in Bellevue Hospital in New York, NY. The reverberations from The Bristol Royal Infirmary Inquiry3 sparked a focus on the issue of patient safety. This issue was reinforced with the dissemination of the Institute of Medicine report, To Err Is Human: Building a Safer Health System 4. Preoccupation with the issue of patient safety has led to many positive outcomes in patient care, but an important side effect has been decreased opportunities for residents for …

The Correlation between Pes Planus and Anterior Knee or Intermittent Low Back Pain

Background: Anterior knee pain and intermittent low back pain are among the most common orthopedic complaints of adolescents. However, little is known about pes planus and its relative risk for these symptoms. The goal of the study was to track the prevalence of pes planus in adolescents, and examine its associated risk to anterior knee pain and intermittent low back pain, respectively. Materials and Methods: A retrospective study of 97,279 military recruits presenting to recruitment centers was conducted. Pes planus was graded by an orthopedist as mild, moderate or severe according to the flattening of the plantar arch and its rigidity to standing on ones toes. Anterior knee pain was diagnosed when symptoms were attributed to the patellofemoral joint. Intermittent low back pain was diagnosed when there was pain but neither abnormal clinical nor radiographic findings. Results: Pes planus was present in 15,698 (16%) individuals. 11,549 (74%), 3,341 (21%) and 808 (5%) were diagnosed as having mild, moderate and severe pes planus, respectively. The prevalence of intermittent low back pain was 5% in both the control and mild pes planus groups, while it was 10% in the moderate and severe pes planus groups (p < 0.0001). The prevalence of anterior knee pain was 4% in both the control and mild pes planus groups, while it was 7% in the moderate and severe pes planus groups (p < 0.0001). Conclusion: Moderate and severe pes planus was associated with nearly double the rate of anterior knee pain and intermittent low back pain, while mild pes planus was associated with no higher rate for these problems. Prophylactic measures may be helpful only in those adolescents with moderate and severe pes planus.

Reflections on Competency-Based Education and Training for Surgical Residents

Although a number of surgical training institutions have started to adopt competency-based education (CBE) frameworks for training, the debate about the value of this model continues. Some proponents regard CBE as a method of guaranteeing residents competence, whereas others consider CBE to be reductive and lacking the richness in experiences that the traditional model offers. In this article, we reflect on CBE and review some salient attempts to implement CBE in surgical education. We identify challenges facing postgraduate surgical education, some of which are motivating educators to consider incorporating CBE into their curricula. We look at some purported advantages and disadvantages of CBE and describe initial reports from CBE programs currently being developed.

Two-stage Revision Arthroplasty for Management of Chronic Periprosthetic Hip and Knee Infection: Techniques, Controversies, and Outcomes

In North America, two-stage revision arthroplasty is the treatment of choice for chronic periprosthetic infection of the hip and knee. Controversy exists regarding the diagnosis of persistent infection, cement spacer design, and duration of antibiotic therapy. Erythrocyte sedimentation rate and C-reactive protein tests have no clear cutoff values for detecting infection before reimplantation of hardware, and aspiration for microbial culture can yield false-negative results. Mobile spacers are as effective as static spacers for eradicating infection, but mobile spacers provide better interim function and may help to make the second stage of surgery technically easier. Some articulating spacer designs have fewer reports of spacer dislocation and fracture than do others. Although prolonged antibiotic therapy has been the standard of care for two-stage procedures, some have suggested that a short course of antibiotics is just as effective. When infection persists despite antibiotic therapy, the second stage of revision arthroplasty should be delayed until the first stage of the procedure is repeated.

Orthopaedic Boot Camp II: Examining the retention rates of an intensive surgical skills course

BACKGROUND We examined retention rates for basic surgical skills taught through a 1-month intensive laboratory boot camp-style course at the onset of residency. METHODS We present data from 3 groups, each composed of 6 residents. The first group consisted of residents from a new competency-based curriculum (CBC). They started residency training with the Toronto Orthopaedic Boot Camp course. The other 2 groups were junior (JR) and senior (SR) residents from a traditional program whose residency training included no such course. Performance on targeted technical skills was tested using an objective structured assessment of technical skills examination 7 months after the onset of training for the CBC and JR groups and at least 43 months after the onset of training for the SR group. RESULTS The mean global rating scale score for the CBC group immediately after the skills course was 4.3, which was maintained 6 months later. There were no significant performance differences between the CBC and SR groups. Both the CBC and SR groups performed significantly better than the JR group (mean global rating scale 3.7; F[2, 15] = 12.269, P < .001). CONCLUSION We conclude that a surgical skills course at the onset of residency is an effective mechanism for teaching targeted technical skills and that skills taught in this manner can have excellent retention rates. Furthermore, an early focus on technical skills allows junior residents to perform at the same level as senior residents for certain tasks and may privilege later learning.

Revision Total Knee Arthroplasty for Component Malrotation is Highly Beneficial: A Case Control Study

Component malrotation is a recognized cause of post total knee arthroplasty (TKA) pain. We reviewed 24 patients who had TKA revision due to component malrotation as the only objective abnormality. Mean combined component rotation was 6.8° excessive internal rotation, as documented by computed tomography. Twenty-four matched control patients had TKA revision due to aseptic loosening. Mean follow-up was 37 months. Preoperative Knee Society Score improved by 49 points at 6 months postoperatively for the malrotation patients and by 39 for the loosening patients. At last follow-up, Knee Society Score was 80 for the malrotation group and 75 for the loosening group. We recommend the use of computed tomography scans in evaluation of all patients with early painful TKAs and no objective evidence of infection. When component malrotation is demonstrated, early revision should be considered.