Search

Arthroplasty implant fracture is a rare but critical complication that requires difficult revision surgery, often with poor results, patient disability, and significant cost. Several reports show component fracture either at the stem or at the neck interface after a relatively short postoperative course. We report such failure after 12 years, suggesting no safe period after which femoral implant fracture does not occur.

Background: Attitudes influence how people make decisions. In an effort to decrease pilot judgment-related accidents, the Federal Aviation Administration teaches new pilots about hazardous attitudes that are believed to be incompatible with safe flight: macho, impulsive, worry, resignation, self-confidence, and antiauthority. If these attitudes are hazardous for pilots and their passengers, they may also be incompatible with the reliable and safe delivery of surgical care., Questions/purposes: The purposes of this study were (1) to ascertain to what extent surgeons harbor hazardous attitudes; and (2) to determine their relationship, if any, to reoperation and readmission rates., Methods: We selected validated aviation psychology tools that are used to measure these attitudes in pilots. We converted the aviation scenarios to analogous situations for surgeons and invited all surgeons from one academic program to participate in this study. A total of 41 surgeons were eligible to participate; 37 (90%) completed the attitude prevalence protocol and 31 (76%) had complete reoperation and readmission data for the correlation and regression analysis. Attending orthopaedic surgeons completed the Modified Surgeon Hazardous Attitude Scale as well as a series of additional instruments., Results: Levels of macho thought to be hazardous in pilots were present in nine (24%) surgeons. Similar, elevated levels of self-confidence were found in three (8%) surgeons. High levels of impulsivity were found in 5% (two surgeons) and high levels of antiauthority were found in 3% (one surgeon). Only one (3%) surgeon reported elevated levels of worry and no surgeon reported hazardous levels of resignation. Thirty percent (11 surgeons) of surgeons harbored at least one elevated attitude level. In a regression model, macho attitude levels predicted 19% of the variation in surgeons' rate of readmissions and reoperations., Conclusions: High levels of hazardous attitudes may not be consistent with the routine delivery of safe surgical care in a teamwork setting where human factors and safe systems are the key to success. Further research is needed to determine if abnormally high levels of these hazardous attitudes impact patient care., Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Background: So-called "hazardous attitudes" (macho, impulsive, antiauthority, resignation, invulnerable, and confident) were identified by the Federal Aviation Administration and the Canadian Air Transport Administration as contributing to road traffic incidents among college-aged drivers and felt to be useful for the prevention of aviation accidents. The concept of hazardous attitudes may also be useful in understanding adverse events in surgery, but it has not been widely studied., Questions/purposes: We surveyed a cohort of orthopaedic surgeons to determine the following: (1) What is the prevalence of hazardous attitudes in a large cohort of orthopaedic surgeons? (2) Do practice setting and/or demographics influence variation in hazardous attitudes in our cohort of surgeons? (3) Do surgeons feel they work in a climate that promotes patient safety?, Methods: We asked the members of the Science of Variation Group-fully trained, practicing orthopaedic and trauma surgeons from around the world-to complete a questionnaire validated in college-aged drivers measuring six attitudes associated with a greater likelihood of collision and used by pilots to assess and teach aviation safety. We accepted this validation as applicable to surgeons and modified the questionnaire accordingly. We also asked them to complete the Modified Safety Climate Questionnaire, a questionnaire assessing the absence of a safety climate that is based on the patient safety cultures in healthcare organizations instrument. Three hundred sixty-four orthopaedic surgeons participated, representing a 47% response rate of those with correct email addresses who were invited., Results: Thirty-eight percent (137 of 364 surgeons) had at least one score that would have been considered dangerously high in pilots (> 20), including 102 with dangerous levels of macho (28%) and 41 with dangerous levels of self-confidence (11%). After accounting for possible confounding variables, the variables most closely associated with a macho attitude deemed hazardous in pilots were supervision of surgical trainees in the operating room (p = 0.003); location of practice in Canada (p = 0.059), Europe (p = 0.021), and the United States (p = 0.005); and being an orthopaedic trauma surgeon (p = 0.046) (when compared with general orthopaedic surgeons), but accounted for only 5.3% of the variance (p < 0.001). On average, 19% of surgeon responses to the Modified Safety Climate Questionnaire implied absence of a safety climate., Conclusions: Hazardous attitudes are common among orthopaedic surgeons and relate in small part to demographics and practice setting. Future studies should further validate the measure of hazardous attitudes among surgeons and determine if they are associated with preventable adverse events. We agree with aviation safety experts that awareness of amelioration of such attitudes might improve safety in all complex, high-risk endeavors, including surgery-a line of thinking that merits additional research.

It is unclear how to interpret ulnar variance (UV) as determined by magnetic resonance imaging (MRI). Using a radiology database, we retrospectively assessed UV on MRI and compared it with UV on radiographs. MR images of 163 wrists (158 patients) were reviewed. Mean (SD) UV was -0.16 (2.43) mm on radiographs, -0.62 (2.41) mm on T1-weighted (bone-to-bone) MRI, and -0.50 (2.38) mm on gradient- echo or short tau inversion recovery (cartilage-to-cartilage) MRI. Compared with MRI, radiographs significantly underestimated the magnitude of negative UV. There was no difference in UV between different hand positions in MRI. Further research is needed to validate the measurement of UV on MRI and to determine its clinical utility.

Background: Medical error is a major cause of preventable morbidity and mortality. Resident fatigue is likely to be a significant contributor., Objectives: We calculated and compared predicted fatigue impairment in surgical residents on varying schedules by using the validated Sleep, Activity, Fatigue, and Task Effectiveness model and Fatigue Avoidance Scheduling Tool; we identified specific times of day and rotations during which residents were most affected, instituted countermeasures, and measured the predicted response., Methods: We compared 4 scheduling patterns: day shift, trauma shift, night shift, and prework hour restriction Q3 call (or every-third-night call). The dependent variables were mean daily effectiveness while at work and the percentage of time residents worked with critical fatigue impairment (defined as an effectiveness score of less than 70 correlated with an increased risk for error and a blood alcohol content of 0.08). Fatigue countermeasures (ie, a 30-minute nap, eliminating 24-hour shifts) were applied to rotations with significant impairment to determine impairment plasticity., Results: CALCULATED MEAN EFFECTIVENESS SCORES AND PERCENTAGE OF TIME SPENT IMPAIRED AT WORK WERE AS FOLLOWS: day shift, 90.3, 0%; trauma shift, 82.0, 7.5%; prework hour restriction Q3 call shift, 80.7, 23%; and night shift, 68.0, 50% (P < .001). Fatigue optimization countermeasures for night shift rotation improved mean daily effectiveness to 87.1 with only 1.9% of time working while impaired (P < .001)., Conclusions: There is a significant potential for fatigue impairment in residents, with work schedule a significant factor. Once targeted, fatigue impairment may be minimized with specific countermeasures. Fatigue optimization tools provide data for targeted scheduling interventions, which reduce fatigue and may mitigate medical error.

Changes in aircraft cabin pressure and its interplay with a fixed diameter fiberglass cylindrical cast and the closed air cells in waterproof cast padding may cause a transient altitude-induced compartment syndrome. In this case series, 2 patients reported transient compartment syndromes that resolved with aircraft decent. As proof of concept, this work displays photographic and video evidence showing the difference in air cell volume from experimental data in a vacuum chamber as well as real-world volume changes at cruise altitude in a commercial airliner. Transient altitude-induced compartment syndromes associated with fiberglass casts using waterproof cast padding are real and surgeons and patients should be advised of this potentially devastating complication.

Hypothesis: A novel approach to identify at-risk periods among orthopedic surgical residents may direct fatigue risk mitigation and facilitate targeted interventions., Design: A prospective cohort study with a minimum 2-week continuous assessment period. Data on sleep and awake periods were processed using the sleep, activity, fatigue, and task effectiveness model., Setting: Rotations at 2 academic tertiary care centers., Participants: Twenty-seven of 33 volunteer orthopedic surgical residents (82%) completed the study, representing 65% (33 of 51) of the orthopedic residency program., Intervention: Residents' sleep and awake periods were continuously recorded via actigraphy, and a daily questionnaire was used to analyze mental fatigue., Main Outcome Measures: Percentage of time at less than 80% mental effectiveness (correlating with an increased risk of error), percentage of time at less than 70% mental effectiveness (correlating with a blood alcohol level of 0.08%), the mean amount of daily sleep, and the relative risk of medical error compared with chance., Results: Residents were fatigued during 48% and impaired during 27% of their time awake. Among all residents, the mean amount of daily sleep was 5.3 hours. Overall, residents' fatigue levels were predicted to increase the risk of medical error by 22% compared with well-rested historical control subjects. Night-float residents were more impaired (P = .02), with an increased risk of medical error (P = .045)., Conclusions: Resident fatigue is prevalent, pervasive, and variable. To guide targeted interventions, fatigue modeling can be conducted in hospitals to identify periods, rotations, and individuals at risk of medical error.

In this case report, we describe a complication of occlusion of a low-flow artery related to traction and compression against the center post of a fracture table during trochanteric femoral nailing. The ischemic limb subsequently underwent urgent revascularization by the vascular surgery team. The patient was placed on anticoagulation and recovered. Radiographically visible vascular plaques should alert the surgeon to potential vascular complications of traction and center-post compression.

Purpose: We modified the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire to be weighted according to a patient's priorities (patient-specific [PS-DASH]) and compared it with the DASH in terms of its mean and variance and its relationship with coping styles (pain avoidance, pain catastrophizing, anxiety sensitivity, and hypochondriasis), depression, and overall stress., Methods: Ninety-eight patients with carpal tunnel syndrome completed questionnaires measuring depression, pain catastrophizing, avoidance, hypochondriasis, anxiety sensitivity, and ordinal measures of self-reported stress and disability. They also completed the DASH and a modification of the DASH that weighted each item according to personal priorities., Results: The DASH scores had a significantly higher mean and greater standard deviation than the PS-DASH (mean +/- standard deviation, 54.1 +/- 16.8 vs 32.7 +/- 11.0). Health anxiety (r = 0.355), anxiety sensitivity (r = 0.258), and pain catastrophizing (r = 0.421) were significantly related to PS-DASH; health anxiety (r = 0.298), depression (r = 0.225), and pain catastrophizing (r = .350) were significantly related to DASH. Multivariable regression analyses were statistically significant, but accounted for only 35% of the variance in PS-DASH and 17% of the variance in DASH. Pain catastrophizing and gender were the sole significant predictors for PS-DASH (B = 0.290, B = 0.384), whereas only pain catastrophizing predicted DASH (B = 0.251)., Conclusions: A version of the DASH weighted according to patient priorities narrowed the variability in DASH scores but did not appear to have sufficient advantage over DASH to warrant this much more cumbersome questionnaire., (Copyright 2010. Published by Elsevier Inc.)

Purpose: We tested the hypothesis that preoperative expectations affect postoperative satisfaction and arm-specific, self-reported health status after elective carpal tunnel release., Methods: Forty-nine patients having elective carpal tunnel release completed questionnaires evaluating self-rated upper extremity-specific disability using the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire, expectations regarding surgery (Preop Expectations Score), personal importance of upper-extremity function, measures of general optimism, the Life Orientation Test (LOT), as well as health-specific optimism, and the Multidimensional Health Locus of Control scale. Six months after surgery, patients completed a 10-point Likert scale to assess satisfaction, the DASH, and measures determining (1) fulfillment of expectations (Postop Met Expectations Score) and (2) relief of specific systems (Postop Help Score)., Results: The DASH scores decreased significantly from an average of 37 points before surgery to an average of 15 points 6 months after carpal tunnel release (p<.001), and patients rated their satisfaction (mean +/- standard deviation) as 8 +/- 3. Preoperative expectations did not correlate with patient satisfaction or postoperative DASH scores. Multivariable analyses determined that patient satisfaction was best predicted by fulfillment of expectations (Postop Help Score alone, accounting for 41% of the variance in scores) and postoperative DASH scores were predicted by a combination of Postop Met Expectations Score and the LOT score (accounting for 31% of the variance in scores)., Conclusions: As measured in this study, the strongest predictor of satisfaction after carpal tunnel release was relief of symptoms, and the strongest predictors of postoperative disability were met expectations and optimism; however, the majority of the variance in postoperative satisfaction remains unexplained., Type of Study/level of Evidence: Prognostic III.

Background: The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is the most widely used upper extremity-specific health-status measure. The DASH score often demonstrates greater variability than would be expected on the basis of objective pathology. This variability may be related to psychosocial factors. The purpose of the present study was to investigate the correlation between the DASH score and psychological factors for specific diagnoses with relatively limited variation in objective pathology., Methods: Two hundred and thirty-five patients with a single, common, discrete hand problem known to have limited variations in objective pathology completed the DASH questionnaire, the Eysenck Personality Questionnaire-Revised (EPQ-R) to assess neuroticism, the Center for Epidemiologic Studies-Depression (CES-D) scale to quantify depressive symptoms, and the Pain Anxiety Symptoms Scale (PASS). Forty-five patients had carpal tunnel syndrome, forty-four had de Quervain tenosynovitis, forty-eight had lateral elbow pain, and seventy-one had a single trigger finger. In addition, twenty-seven patients were evaluated six weeks after a nonoperatively treated fracture of the distal part of the radius. Relationships between psychosocial factors and the DASH score were determined., Results: A significant positive correlation between the DASH score and depression was noted for all diagnoses (r = 0.38 to 0.52; p < 0.01 for all). The DASH score also correlated with pain anxiety for four of the five diagnoses (carpal tunnel syndrome, r = 0.40; de Quervain tendinitis, r = 0.46; lateral elbow pain, r = 0.42; and trigger finger, r = 0.24) (p < 0.05 for all). The DASH score was not correlated with neuroticism for any diagnosis. There was a highly significant effect of depression (as measured with the CES-D score) on the DASH score for all diagnoses. Both the CES-D score (F = 62.68, p < 0.0001) and gender (F = 11.36, p < 0.001) were independent predictors of the DASH score., Conclusions: Self-reported upper extremity-specific health status as measured with the DASH score correlates with depression and pain anxiety but not neuroticism. These data support the contention that psychosocial factors have a strong influence on health-status measures.

Background: Psychological and personality factors may be as important as, or more important than, pathological processes in the experience of pain, particularly in patients whose pain has a vague or uncertain source., Methods: Validated measures of psychological factors were used to prospectively evaluate fifty-six patients with a single, discrete pain complaint and fifty-one patients with vague, diffuse idiopathic arm pain. Pain was assessed with use of 10-point Likert scales, the Pain Anxiety Symptoms Scale, the Pain Catastrophizing Scale, the Wahler Physical Symptom Inventory, the Body Consciousness Questionnaire, and the Multidimensional Health Locus of Control Scale., Results: Patients with idiopathic arm pain reported more severe pain at rest (p = 0.02) and with repeated movements (p = 0.01); exhibited higher levels of cognitive anxiety (p = 0.008); demonstrated greater helplessness (p = 0.002), pain magnification (p = 0.007), and overall catastrophic coping mechanisms for dealing with pain (p = 0.005); and showed a tendency for increased somatic complaining (p = 0.07). A multiple logistic regression model identified the total score on the Pain Catastrophizing Scale as the sole predictor of idiopathic pain complaints., Conclusions: Pain complaints without a clear physical cause are common and are frustrating for both patients and physicians. Awareness of the psychological factors associated with idiopathic arm pain may lead to more effective interventions designed to improve coping mechanisms while at the same time limiting the use of meddlesome and potentially harmful diagnoses and treatments.

Poor bone quality increases the technical difficulty and complications of operative treatment of nonunions and delayed unions of the diaphyseal humerus in older patients. Plates with screws that lock to the plate (transforming each screw into a fixed blade) are intended to improve the fixation of poor quality bone. Twenty-four patients (20 women, four men) with an average age of 72 years (range, 52-86 years) were followed up for a minimum of 12 months after locking compression plate fixation of an osteopenic delayed union (nine patients) or nonunion (15 patients) of the diaphyseal humerus. Twelve patients had iliac crest cancellous bone grafts, two patients had local graft, and 13 patients had demineralized bone applied to the fracture site. All the fractures eventually healed; two healed after a second procedure for autogenous bone grafting in patients who initially received demineralized bone. Using a modification of the Constant and Murley shoulder score, the results were good or excellent in 22 patients, and fair in two patients. Locking compression plates provide stable fixation of poor quality bone in patients with delayed union or nonunion of the humerus. Successful union and restoration of function are achieved in most patients. We no longer consider osteoporosis a contraindication to operative fixation of an ununited fracture of the humeral diaphysis.