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Charles William Hargett,1 Joseph P Doty,2 Jennifer N Hauck,3 Allison MB Webb,4 Steven H Cook,5 Nicholas E Tsipis,4 Julie A Neumann,6 Kathryn M Andolsek,7 Dean C Taylor6 1Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, 2Feagin Leadership Program, 3Department of Anesthesiology, 4School of Medicine, 5Department of Neurosurgery, 6Department of Orthopaedic Surgery, 7Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC, USA Purpose: Despite increasing awareness of the importance of leadership in healthcare, our understanding of the competencies of effective leadership remains limited. We used a concept mapping approach (a blend of qualitative and quantitative analysis of group processes to produce a visual composite of the group’s ideas) to identify stakeholders’ mental model of effective healthcare leadership, clarifying the underlying structure and importance of leadership competencies.Methods: Literature review, focus groups, and consensus meetings were used to derive a representative set of healthcare leadership competency statements. Study participants subsequently sorted and rank-ordered these statements based on their perceived importance in contributing to effective healthcare leadership in real-world settings. Hierarchical cluster analysis of individual sortings was used to develop a coherent model of effective leadership in healthcare.Results: A diverse group of 92 faculty and trainees individually rank-sorted 33 leadership competency statements. The highest rated statements were “Acting with Personal Integrity”, “Communicating Effectively”, “Acting with Professional Ethical Values”, “Pursuing Excellence”, “Building and Maintaining Relationships”, and “Thinking Critically”. Combining the results from hierarchical cluster analysis with our qualitative data led to a healthcare leadership model based on the core principle of Patient Centeredness and the core competencies of Integrity, Teamwork, Critical Thinking, Emotional Intelligence, and Selfless Service.Conclusion: Using a mixed qualitative-quantitative approach, we developed a graphical representation of a shared leadership model derived in the healthcare setting. This model may enhance learning, teaching, and patient care in this important area, as well as guide future research. Keywords: core competencies, healthcare leadership, medical education, mental models, mixed methods research

Ewing sarcomas are malignant neoplasm entities typically found in children and adolescents. Early detection is crucial for therapy and prognosis. Due to the low incidence the general experience as well as according data is limited. Novel support tools for diagnosis, such as deep learning models for image interpretation, are required. While acquiring sufficient data is a common obstacle in medicine, several techniques to tackle small data sets have emerged. The general necessity of large data sets in addition to a rare disease lead to the question whether transfer learning can solve the issue of limited data and subsequently support tasks such as distinguishing Ewing sarcoma from its main differential diagnosis (acute osteomyelitis) in paediatric radiographs. 42,608 unstructured radiographs from our musculoskeletal tumour centre were retrieved from the PACS. The images were clustered with a DeepCluster, a self-supervised algorithm. 1000 clusters were used for the upstream task (pretraining). Following, the pretrained classification network was applied for the downstream task of differentiating Ewing sarcoma and acute osteomyelitis. An untrained network achieved an accuracy of 81.5%/54.2%, while an ImageNet-pretrained network resulted in 89.6%/70.8% for validation and testing, respectively. Our transfer learning approach surpassed the best result by 4.4%/17.3% percentage points. Transfer learning demonstrated to be a powerful technique to support image interpretation tasks. Even for small data sets, the impact can be significant. However, transfer learning is not a final solution to small data sets. To achieve clinically relevant results, a structured and systematic data acquisition is of paramount importance.

Bone tumours are a rare and often highly malignant entity. Early clinical diagnosis is the most important step, but the difficulty of detecting and assessing bone malignancies is in its radiological peculiarity and limited experience of non-experts. Since X-ray imaging is the first imaging method of bone tumour diagnostics, the purpose of this study is to develop an artificial intelligence (AI) model to detect and segment the tumorous tissue in a radiograph. We investigated which methods are necessary to cope with limited and heterogeneous data. We collected 531 anonymised radiographs from our musculoskeletal tumour centre. In order to adapt to the complexity of recognizing the malignant tissue and cope with limited data, transfer learning, data augmentation as well as several architectures, some of which were initially designed for medical images, were implemented. Furthermore, dataset size was varied by adding another bone tumour entity. We applied a data split of 72%, 18%, 10% for training, validation and testing, respectively. To provide statistical significance and robustness, we applied a cross-validation and image stratification with respect to tumour pixels present. We achieved an accuracy of 99.72% and an intersection over union of 87.43% for hold-out test data by applying several methods to tackle limited data. Transfer learning and additional data brought the greatest performance increase. In conclusion, our model was able to detect and segment tumorous tissue in radiographs with good performance, although it was trained on a very limited amount of data. Transfer Learning and data augmentation proved to significantly mitigate the issue of limited data samples. However, to accomplish clinical significance, more data has to be acquired in the future. Through minor adjustments, the model could be adapted to other musculoskeletal tumour entities and become a general support tool for orthopaedic surgeons and radiologists.

Closing the knowledge gap for current practicing nurses in the Institute of Medicine (IOM) core competencies is critical to providing safe patient care. The National Quality Forum (NQF) nurse scholar program is one organization's journey to close the gap in the IOM core competencies in a large teaching organization. The NQF nurse scholar program is positioned to provide a plan to assist current nurses to accelerate their learning about quality improvement, evidence-based practice, and informatics, 3 of the core competencies identified by the IOM, and focus on application of skills to NQF nurse-sensitive measures. Curriculum outline, educational methodologies, administrative processes, and aims of the project are discussed. [ABSTRACT FROM AUTHOR]

Teaching learners in the affective domain demands strong educational skills that go beyond the lecture mode. Affective domain strategies fit well when teaching staff about institutional values, such as mission or philosophy. Instilling these values in staff can directly impact the quality of patient care. The purpose of this article is to describe strategies for teaching in the affective domain and discuss an education project to teach preceptors about institutional culture and core values. Similar education can be replicated for other institutions. Evaluation of this teaching project is also discussed. [ABSTRACT FROM AUTHOR]

Saturated fatty acids have been traditionally thought to be detrimental in circulation. However, we describe the beneficial effects of palmitic and stearic acid methyl esters as it relates to neuroprotection and cerebral vasodilatory properties in global and focal cerebral ischemia. The methyl esterification of fatty acids is not prominent in nature. However, it seems to have biological activity related to neuroprotection/vasodilation. We will discuss the etiology of cerebral ischemia such as stroke and cardiac arrest in terms of current and future treatment modalitiesas it relates to fatty acid-based therapies. This review is based on the meeting presentation at the “The Journées Chevreul, Lipids & Brain III 2015” in Paris on 16–18 March, 2015.

Abstract Background Three-dimensional (3D) visualization is thought to improve the anatomical understanding of clinicians, thus improving patient safety. Case presentation A 58-year-old male was admitted to our hospital in April 2007 with a suspected metastasis of a sigmoid cancer in the Couinaud segment (CS) 7. The anatomical situation of this patient was analyzed using both a CT scan and 3D images. The initial CT scan revealed that the proximal part of the middle hepatic vein was completely missing and the metastasis in the CS 7 was closely attached to the right hepatic vein. After analyzing additional 3D images, it became clear that due to the close proximity of metastasis and right hepatic vein, the resection of the right hepatic vein was inevitable. Based on this 3D analysis, it was decided to perform a right-sided hemihepatectomy. In this case report, 3D visualization resulted in a faster and clearer understanding of the unique anatomical situation in a patient with complicated liver anatomy than transversal CT images. Conclusion The here presented data shows for the first time 3D visualization of intravenous anastomoses in the human liver. The information offered by 3D visualization is not redundant but rather serves as a true source of additional information, indicating the potential benefit of 3D visualization in surgical operation planning.

Demineralized bone matrix (DBM) has been shown to have positive effects on union rates in many orthopedic subspecialties; however, minimal evidence exists about bone graft substitutes in foot and ankle surgery. The purpose of this study is to compare nonunion rates in arthroscopic ankle arthrodesis in patients receiving DBM with those without. We hypothesized DBM to be associated with a decreased risk of nonunion. This retrospective review includes 516 consecutive ankle arthrodesis cases from March 2002 to May 2016. Of these, 58 ankles (56 patients) that underwent primary arthroscopic ankle arthrodesis met the inclusion criteria, and 31 of these ankles received DBM, while 27 did not. Nonunion was assessed by clinical examination and routine postoperative radiographs. If nonunion was suspected, a computed tomography (CT) scan was performed. The primary outcome measure was nonunion rate. Secondary outcome measures included wound complications, return to operating room (OR), and rate of postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE). From the study cases, 58 were available for final follow-up. The average age was 55.9 years (±17.4), and mean follow-up was 43.0 months (range 6.3-119.4). There was no difference in nonunion rate in patients who received DBM (4/31, 12.9%) versus those who did not (4/27, 14.8%) ( p = 0.83). Similarly, when comparing the two groups, there were no statistically significant differences in superficial wound complications (6.5% vs. 3.7%, p = 1.0) or rate of return to OR (29% or 0.037/person-years vs. 37% or 0.099/person-years; p = 0.20). No major complications including deep wound infections, DVTs, or PEs occurred. This is the largest study to directly compare nonunion rates and complications for patients receiving DBM versus those who did not in primary arthroscopic ankle arthrodesis. No significant association was found between DBM usage and risk of nonunion, wound complications, return to OR, or postoperative DVT or PE development.

Tibiotalar arthrodesis successfully treats ankle arthritis but carries risk of nonunion. It is unclear whether concurrent distal tibiofibular arthrodesis affects tibiotalar nonunion rate. The purpose of this study is to compare tibiotalar nonunion and complication rates in patients with versus without a distal tibiofibular arthrodesis. This is a retrospective review of 516 consecutive ankle arthrodesis performed between March 2002 and May 2016. A total of 319 ankles (312 patients) underwent primary, open tibiotalar arthrodesis (227 with distal tibiofibular arthrodesis, 92 without). Primary outcome measure was nonunion rate. Secondary outcome measures were time to tibiotalar union, rate of development of post-operative deep vein thrombosis (DVT)/pulmonary embolism (PE), rate of deep wound complications, and rate of return to operating room (OR). No differences in nonunion rates were observed in both cohorts of patients with versus without distal tibiofibular arthrodesis: 17/227 (7.5%) versus 11/92 (12%) ( p = 0.2), respectively, odds ratio was 0.74, 95% CI: 0.29~2.08 ( p = 0.55). There was no difference in deep wound complications (5.3% versus 10.9%, p = 0.42), time to union (3.7 months versus 4.1 months, p = 0.72), or rate of development of DVT/PE (5.2% versus 2.2%, p = 0.18) between patients with and without distal tibiofibular arthrodesis, respectively. This is the first study directly comparing nonunion and complication rates in primary, open ankle arthrodesis with and without distal tibiofibular arthrodesis. Inclusion of the distal fibular joint with the tibiotalar fusion was not associated with a change in tibiotalar nonunion rate, time to union, wound complications, or postoperative DVT/PE.

A cavovarus deformity results from muscle imbalances in the foot. There are several etiologies of a cavovarus foot including congenital, neurologic, post-traumatic, and idiopathic. Charcot-Marie-Tooth disease is a common genetic cause of cavovarus foot. History, physical examination, and imaging help determine appropriate treatment. The deformity can be flexible or rigid and can present in children or adults, thus treatment should be individualized to the patient. Non-operative management includes shoe wear modification, physical therapy, and bracing. Operative management consists of soft tissue releases, tendon transfers, osteotomies, arthrodesis, and repair/reconstruction of lateral ankle ligaments and peroneal tendons., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Infection is a concern after all orthopedic procedures, including shoulder surgery. This systematic review of literature aimed to determine risk factors for infection as well as the availability and effectiveness of measures utilized to prevent infection after elective shoulder surgery., Methods: An electronic database search was performed using MEDLINE (1950-October 2017), EMBASE (1980-October 2017), CINAHL (1982-October 2017), and the Cochrane database to identify studies reporting a risk factor or preventive measure for infection after shoulder surgery., Results: Fifty-one studies were eligible for inclusion. Risk factors identified for infection were male sex, the presence of hair, receiving an intra-articular cortisone injection within the 3 months prior to surgery, smoking, obesity, and several comorbidities. The only preventive measure with level I evidence was for the use of chlorhexidine wipes for cleansing the skin in the days prior to surgery and for the use of ChloraPrep or DuraPrep over povodine and iodine to prep the skin at the time of surgery. Level II-IV evidence was found for other infection prevention methods such as intravenous antibiotic prophylaxis., Conclusion: There are many risk factors associated with developing an infection after elective shoulder surgery. Many preventive measures have been described which may decrease the risk of infection; however, most lack a high level evidence to support them. The findings of this systematic review are clinically relevant as it has been shown that infection after shoulder surgery results in poor patient-reported outcomes and pose a significant financial burden. As surgeons the goal should be to prevent infections to avoid the morbidity for patients and the increased cost for society., Level of Evidence: IV systematic review of literature.

Background: Radiocapitellar pathology after traumatic injury to the elbow can be challenging to treat. The anconeus interposition arthroplasty has been proposed to treat radiocapitellar or proximal radioulnar joint dysfunction and pain, or both. This study evaluated whether radial head excision (native or prosthetic), followed by an anconeus interposition arthroplasty, relieves pain and improves subjective and objective elbow function in patients with post-traumatic radiocapitellar pathology., Methods: A retrospective comparative case series was performed of 50 consecutive patients who underwent a native radial head excision or radial head implant excision, followed by an anconeus interposition arthroplasty. Clinical outcome scores, range of motion, and proximal radius migration were evaluated in patients with at least 2 years of follow-up., Results: Included were 23 patients (11 native and 12 prosthetic radial heads) with a mean age of 41 years. Average follow-up was 38 months. Overall, significant improvement was obtained in the Disabilities of the Arm, Shoulder and Hand and visual analog scale scores. Range of motion significantly improved from preoperatively to postoperatively. Patients with a native radial head excision scored better on the Single Assessment Numeric Evaluation (76.8 vs. 56.3, P = .037) and obtained significantly more flexion postoperatively (141° vs. 123°, P = .016). Mild wrist pain developed in 3 patients, but no further intervention was required. The overall complication rate was 13%, and 5 patients required reoperation., Conclusions: Anconeus interposition arthroplasty performed after radial head resection in native and prosthetic groups is a viable adjunct in the operative treatment of patients with post-traumatic radiocapitellar pathology. However, whether anconeus interposition arthroplasty alone produced the favorable clinical results of this study was difficult to determine., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: An anatomic double-tunnel (DT) reconstruction technique has been widely adopted to reconstruct the ruptured coracoclavicular (CC) ligaments seen with high-grade acromioclavicular (AC) joint injuries. However, the anatomic DT reconstruction has been associated with the risk of clavicle fractures, which may be problematic, particularly for contact athletes. Purpose/Hypothesis: The purpose was to compare a single-tunnel (ST) CC ligament reconstruction for AC joint injuries with the native state as well as with the more established anatomic DT CC ligament reconstruction. The hypothesis was that ST CC ligament reconstruction would demonstrate biomechanical properties similar to those of the native state and the DT CC ligament reconstruction., Study Design: Controlled laboratory study., Methods: Eighteen fresh-frozen human cadaveric shoulders (9 matched pairs) with mean ± SD age of 55.5 ± 8.5 years underwent biomechanical testing. One specimen of each matched pair underwent a ST CC ligament reconstruction and the second, a DT CC ligament reconstruction. The ST and DT CC ligament reconstruction techniques involved a 5-mm distal clavicle excision, avoided coracoid drilling, and utilized a 3.0-mm suture anchor to fix the excess lateral limb to reconstruct the superior AC joint capsule. The ST CC ligament reconstruction technique additionally included a 1.3-mm suture tape to help avoid a sawing effect, as well as a dog-bone button over the clavicular tunnel to increase stability of the construct. All specimens were tested to 70 N in 3 directions (superior, anterior, and posterior) in the intact and reconstructed states. The ultimate load, yield load, stiffness, and mode of failure of the reconstructed specimens were tested., Results: There were no significant differences in translation at 70 N in the superior ( P = .31), anterior ( P = .56), and posterior ( P = .35) directions between the ST CC ligament reconstruction and the intact state. The ultimate load to failure, yield load, and stiffness in the ST and DT groups were also not significantly different. There were no distal clavicle fractures in load-to-failure testing in the ST or DT group., Conclusion: In this biomechanical study, ST CC ligament reconstruction demonstrates biomechanical properties comparable to the intact state. Additionally, use of the ST CC ligament reconstruction shows biomechanical properties similar to the DT CC ligament reconstruction technique while theoretically posing less risk of clavicle fracture., Clinical Relevance: This study suggests that the ST CC ligament reconstruction has biomechanical properties equivalent to the DT CC ligament reconstruction with less theoretical risk of clavicle fracture.

Context: Current perception dictates that glenohumeral internal rotation deficit (GIRD) is a chronic adaptation that leads to an increased risk of pathologic conditions in the dominant shoulder or elbow of overhead athletes., Objective: To determine whether adaptations in glenohumeral range of motion in overhead athletes lead to injuries of the upper extremity, specifically in the shoulder or elbow., Data Sources: An electronic database search was performed using Medline, Embase, and SportDiscus from 1950 to 2016. The following keywords were used: GIRD, glenohumeral internal rotation deficit, glenohumeral deficit, shoulder, sport, injury, shoulder joint, baseball, football, racquet sports, volleyball, javelin, cricket, athletic injuries, handball, lacrosse, water polo, hammer throw, and throwing injury., Study Selection: Seventeen studies met the inclusion criteria for this systematic review. Of those 17 studies, 10 included specific range of motion measurements required for inclusion in the meta-analysis., Study Design: Systematic review and meta-analysis., Level of Evidence: Level 4., Data Extraction: Data on demographics and methodology as well as shoulder range of motion in various planes were collected when possible. The primary outcome of interest was upper extremity injury, specifically shoulder or elbow injury., Results: The systematic review included 2195 athletes (1889 males, 306 females) with a mean age of 20.8 years. Shoulders with GIRD favored an upper extremity injury, with a mean difference of 3.11° (95% CI, -0.13° to 6.36°; P = 0.06). Shoulder total range of motion suggested increased motion (mean difference, 2.97°) correlated with no injury ( P = 0.11), and less total motion (mean difference, 1.95°) favored injury ( P = 0.14). External rotational gain also favored injury, with a mean difference of 1.93° ( P = 0.07)., Conclusion: The pooled results of this systematic review and meta-analysis did not reach statistical significance for any shoulder motion measurement and its correlation to shoulder or elbow injury. Results, though not reaching significance, favored injury in overhead athletes with GIRD, as well as rotational loss and external rotational gain.

Background: Avoiding delay in the surgical management of pectoralis major (PM) ruptures optimizes outcomes. However, this is not always possible, and when a tear becomes chronic or when a subacute tear has poor tissue quality, a graft can facilitate reconstruction., Purpose: The primary aim was to evaluate the clinical outcomes of PM reconstruction with dermal allograft augmentation for chronic tears or for subacute tears with poor tissue quality. A second aim was to determine patient and surgical factors affecting outcome., Study Design: Case series; Level of evidence, 4., Methods: Nineteen consecutive patients (19 PM ruptures) with a mean ± SD age of 39.1 ± 8.4 years were retrospectively reviewed at 26.4 ± 16.0 months following PM tendon reconstruction with dermal allograft. Surgery was performed at 19.2 ± 41.2 months after injury (median, 7.6 months; range, 1.1-185.4 months). Several outcome scores were recorded pre- and postoperatively, including Disabilities of the Arm, Shoulder, and Hand (DASH), as well as visual analog scale (VAS) (range, 0-10; 0 = no pain) and Single Assessment Numeric Evaluation (SANE). Range of motion, Constant score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test score, and complications/reoperations were recorded postoperatively., Results: Scores improved significantly for the DASH (preoperative, 34.9; postoperative, 8.0; P < .001) and VAS (preoperative, 5.0; postoperative, 1.5; P = .011). There was a trend toward improved SANE scores (preoperative, 15.0; postoperative, 80.0; P = .097), but the difference was not statistically significant, likely because of the small number of patients having preoperative SANE scores for review. Increased age was associated with higher VAS scores ( r = 0.628, P = .016) and less forward flexion ( r = -0.502, P = .048) and external rotation ( r = -0.654, P = .006). Patients with workers' compensation had lower scores for 3 measures: SANE (75.8 vs 88.4, P = .040), Constant (86.7 vs 93.4, P = .019), and ASES (81.9 vs 97.4, P = .016). Operating on the dominant extremity resulted in lower Constant scores (87.8 vs 95.4, P = .012). A 2-head tendon tear (107.5° vs 123.3°, P = .033) and the use of >1 graft (105.0° vs 121.3°, P = .040) resulted in decreased abduction., Conclusion: This was the first large series to observe patients with chronic or subacute PM tendon tears treated with dermal allograft reconstruction. PM tendon reconstruction with dermal allografts resulted in good objective and subjective patient-reported outcomes., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.M.I. is a paid consultant for Acumed and Arthrex; is a paid speaker for Acumed, Arthrex, and Tornier; receives research support from Acument; and receives royalties from Tornier.

Ligamentum teres (LT) tears are a pathologic condition being identified at increasing frequency because of growing use of hip arthroscopy. The exact role of the LT is not well understood, but it has been shown in recent biomechanical studies to contribute to hip stability. Patients with hip pain, instability, and/or mechanical symptoms with advanced imaging findings showing LT pathology may benefit from an LT augmentation. We present an arthroscopic-assisted LT augmentation technique, which can be performed as an isolated procedure or in conjunction with an arthroscopic labral repair and/or debridement, chondroplasty, and femoroplasty.

Background: Management of massive rotator cuff tears in shoulders without glenohumeral arthritis remains problematic for surgeons. Repairs of massive rotator cuff tears have failure rates of 20% to 94% at 1 to 2 years postoperatively as demonstrated with arthrography, ultrasound, and magnetic resonance imaging. Additionally, inconsistent outcomes have been reported with debridement alone of massive rotator cuff tears, and limitations have been seen with other current methods of operative intervention, including arthroplasty and tendon transfers., Hypothesis: The use of interposition porcine acellular dermal matrix xenograft in patients with massive rotator cuff tears will result in improved subjective outcomes, postoperative pain, function, range of motion, and strength., Study Design: Case series; Level of evidence, 4., Methods: Sixty patients (61 shoulders) were prospectively observed for a mean of 50.3 months (range, 24-63 months) after repair of massive rotator cuff tears with porcine acellular dermal matrix xenograft as an interposition graft. Subjective outcome data were obtained with visual analog scale for pain score (0-10, 0 = no pain) and Modified American Shoulder and Elbow Surgeons (MASES) score. Active range of motion in flexion, external rotation, and internal rotation were recorded. Strength in the supraspinatus and infraspinatus muscles was assessed manually on a 10-point scale and by handheld dynamometer. Ultrasound was used to assess the integrity of the repair during latest follow-up., Results: Mean visual analog scale pain score decreased from 4.0 preoperatively to 1.0 postoperatively ( P < .001). Mean active forward flexion improved from 140.7° to 160.4° ( P < .001), external rotation at 0° of abduction from 55.6° to 70.1° ( P = .001), and internal rotation at 90° of abduction from 52.0° to 76.2° ( P < .001). Supraspinatus manual strength increased from 7.7 to 8.8 ( P < .001) and infraspinatus manual strength from 7.7 to 9.3 ( P < .001). Mean dynamometric strength in forward flexion was 77.7 N in nonoperative shoulders (shoulder that did not undergo surgery) and 67.8 N ( P < .001) in operative shoulders (shoulder that underwent rotator cuff repair with interposition porcine dermal matrix xenograft). Mean dynamometric strength in external rotation was 54.5 N in nonoperative shoulders and 50.1 N in operative shoulders ( P = .04). Average postoperative MASES score was 87.8. Musculoskeletal ultrasound showed that 91.8% (56 of 61) of repairs were fully intact; 3.3% (2 of 61), partially intact; and 4.9% (3 of 61), not intact., Conclusion: Patients who underwent repair of massive rotator cuff tears with interposition porcine acellular dermal matrix graft have good subjective function as assessed by the MASES score. Patients have significant improvement in pain, range of motion, and manual muscle strength. Postoperative ultrasound demonstrated that the repair was completely intact in 91.8% of patients, a vast improvement compared with results previously reported for primary repairs of massive rotator cuff tears.

Synovial chondromatosis is a rare, benign condition of unknown etiology in which the synovium undergoes metaplasia leading to cartilaginous nodules that ultimately break free, mineralize, and even ossify. The most commonly involved joint is the knee. Patients may be asymptomatic or may present with pain, swelling, and limited range of motion. Plain radiographs can be diagnostic and mineralized nodules are pathognomonic. Recommended treatment involves arthroscopic or open removal of loose bodies with or without a synovectomy to prevent further articular and periarticular destruction and to relieve symptoms.

Symptomatic subfibular and/or lateral talocalcaneal impingement in pediatric patients may result from an accessory anterolateral talar facet (AALTF). This impingement may cause pain and disability and may limit athletic performance in high-level athletes. We report the case of a 12-year-old female competitive gymnast who had refractory, lateral-sided right ankle pain for 4 months and underwent right ankle arthroscopic resection of the AALTF causing impingement. Standard medial and anterolateral portals with the addition of an accessory anterolateral-distal portal were used in conjunction with a 30° 2.7-mm-diameter arthroscope. The AALTF was resected with a combination of a shaver and a motorized rasp. Intraoperative fluoroscopy was used to verify successful debridement of the bony facet. This case illustrates that arthroscopic debridement is a technique to treat subfibular and/or talocalcaneal impingement associated with an AALTF.

Rates of medial and/or lateral gutter impingement after total ankle replacement are not insignificant. If impingement should occur, it typically arises an average of 17 months after total ankle replacement. Our patient underwent treatment for right ankle medial gutter bony impingement with arthroscopic debridement 5 years after her initial total ankle replacement. Standard anteromedial and anterolateral portals and a 30° 2.7-mm-diameter arthroscope were used. An aggressive soft-tissue and bony resection was performed using a combination of curettes, a 3.5-mm shaver, a 5.5-mm unsheathed burr, a drill, and a radiofrequency ablator. This case shows that arthroscopic treatment is an effective and potentially advantageous alternative to open treatment of impingement after total ankle replacement. In addition, symptoms of impingement often improve in a short amount of time after arthroscopic debridement of the medial and/or lateral gutter.

This article describes the processes used to implement a pressure ulcer management program in a Midwest academic medical center, which led to a decrease in reportable pressure ulcers. A learning needs assessment was completed, and a workgroup was formed to address the learning needs. Methods, materials, and processes included lectures, technology-enhanced learning, and interactive stations with mannequins and pressure ulcer moulages. The processes and outcome measures used to measure effectiveness of the program are discussed.

Background: The Akin proximal phalangeal osteotomy is commonly used in conjunction with metatarsal osteotomies to treat hallux valgus. Multiple fixation methods including suture, wire, screw, and staple fixation have been described. The aims of this study were to assess the intraoperative and postoperative complications and to evaluate short-term postoperative outcomes in patients who underwent Akin osteotomy with staple fixation., Methods: Forty-four patients (51 feet) with painful hallux valgus were retrospectively reviewed at an average of 40.4 ± 15.8 (range, 25.9 to 79.9) weeks following an Akin osteotomy with staple fixation. Patient reported preoperative and postoperative Visual Analog Score (VAS) (0 to 10, 0 = no pain) was recorded. Level of activity was reported postoperatively. Hallux valgus angles (HVAs), intermetatarsal angles (IMAs), and hallux valgus interphalangeus angles (IPAs) were evaluated on preoperative as well as final postoperative radiographs. Postoperative clinical and radiographic examinations were used to evaluate for complications., Results: Mean VAS improved from 4.4 ± 2.6 to 1.0 ± 1.2 (P < .001). Activity level was classified as ability to bear weight as tolerated 3/51 (5.9%), ambulate 1 to 4 blocks 2/51 (3.9%), ambulate a minimum of 6 blocks 18/51 (35.3%), and ambulate an unlimited distance 28/51 (59.4%). Average HVA, IMA, and IPA improved from 25.6 ± 10.0 degrees to 14.1 ± 8.1 degrees (P < .001), 13.1 ± 4.6 degrees to 8.0 ± 3.0 degrees (P < .001), and 7.9 ± 3.4 degrees to -3.1 ± 6.4 degrees (P < .001), respectively. No major postoperative complications, including infections, nonunions, or recurrent deformities, were recorded. Two patients sustained breaches of the lateral cortex, but this was without appreciable complication. Three patients (5.9%) reported unilateral proximal-medial great phalanx tenderness. There was 1 revision for persistent deformity, specifically in the HVA and IPA angles., Conclusion: Akin osteotomy with staple fixation was a safe and effective procedure as part of a hallux valgus correction with improvement in pain and hallux valgus deformity with a low risk for complications., Level of Evidence: Level IV, case series., (© The Author(s) 2014.)

Synovial chondromatosis is an uncommon condition, and involvement of the shoulder is even more rare. We report on a 39-year-old female who presented with symptoms, radiographic features, and intraoperative findings consistent with multiple subacromial loose bodies resulting in a partial-thickness, bursal-sided rotator cuff tear of the supraspinatus muscle. She was treated with an arthroscopic removal of loose bodies, complete excision of the subacromial/subdeltoid bursa, acromioplasty, and rotator cuff repair. To our knowledge, this is the first report of arthroscopic treatment for a bursal-sided, partial-thickness rotator cuff tear treated with greater than two-year clinical and radiographic follow-up. We utilized shoulder scores, preoperative and postoperative range of motion, and imaging to assess the results of treatment and surveillance for recurrence in our patient after two-year follow-up.

Traumatic hip dislocations are associated with chondral and labral pathology as well as loose bodies that can be incarcerated in the joint. These types of injury often lead to traumatic arthritis. In some cases an osseo-labral fragment may become incarcerated in the joint that is not readily visualized preoperatively. In place of open surgery, hip arthroscopy permits a technique to remove loose bodies and repair labral tears to restore joint congruity and achieve fracture reduction and fixation.

Flexor tendon injuries are not common in most sporting venues; however, recognition of the pertinent anatomy, clinical findings, and the utility of diagnostic imaging will assist the clinician in a thorough evaluation of the athlete's hand. Open injuries demand immediate wound care and evaluation as to the integrity of the flexor apparatus; however, closed injuries often present with the challenges of timing: delayed injury presentation and pressures of intervention and return to play. The purpose of this article is to provide a review of the pertinent anatomy of the flexor apparatus of the hand, to identify key aspects of the patient history, clinical evaluation, and diagnostic testing relevant to flexor function, and to discuss treatment options in the setting of injuries to the flexor tendons and flexor pulley system of the hand.

Physician shortages in the United States are now recognized broadly and widespread by specialty and geography. While supply is increasing, demand inexorably rises. This situation will probably be further stressed post implementation of healthcare reform. The variations by region and by state are many and significant; this complexity is not fully understood nor yet characterized. Trends similar to the averages of the US have been identified in Louisiana, including the aging of physicians. Lack of physicians, both specialists and generalists, has been reported to compromise quality and effectiveness of healthcare. Thus, the importance of matching up supply and demand is evident. The supply of physicians is increasing in absolute number and in the physicians-to-population ratio. Variations in population, aging, geography, and specialties indicate, in some areas, that this may not be enough to deal with the increasing demand. This paper aims to assess historically how physician shortages may affect the balance of supply and demand in future healthcare delivery, particularly in Louisiana.

Establishing a thorough and effective competency assessment program is essential to meeting standards of regulatory bodies and providing quality care. Nursing education specialists continue to strive to provide a competency assessment process that is meaningful and uncomplicated. This article describes the implementation of a nursing competency assessment program in a large midwestern medical center that spans the continuum of care and incorporates all nursing roles that require nursing licensure, including advanced practice nurses, into one centralized nursing competency program. Competency program infrastructure, topic identification, documentation to support the evaluation and validation process, and continuous improvement opportunities are described.