Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 467 | Issue 2 | Feb, 2009

An Introduction to Medical Malpractice in the United States

B. Sonny Bal MD, MBA Medical malpractice law in the United States is derived from English common law, and was developed by rulings in various state courts. Medical malpractice lawsuits are a relatively common occurrence in the United States. The legal system is designed to encourage extensive discovery and negotiations between adversarial parties with the goal of resolving the dispute without going to jury trial. The injured patient must show that the physician acted negligently in rendering care, and that such negligence resulted in injury. To do so, four legal elements must be proven: (1) a professional duty owed to the patient; (2) breach of such duty; (3) injury caused by the breach; and (4) resulting damages. Money damages, if awarded, typically take into account both actual economic loss and noneconomic loss, such as pain and suffering.

Beyond Informed Consent: Educating the Patient

Lawrence H. Brenner JD, Alison Tytell Brenner BA, Daniel Horowitz MD The informed consent doctrine was conceived as a basis for allowing patients to meaningfully participate in the decision-making process. It has evolved into a formal, legal document that reflects a desire by physicians and surgeons to have patients execute “waivers of liability.” In the process it has lost its educational value by shifting the emphasis to obtaining a “preoperative release” from an exchange of information upon which a patient can make important decisions about their healthcare choices. This is unfortunate because, in the process, both patients and physicians have suffered. Patients have become alienated from the informed consent process and, paradoxically, physicians and surgeons may have created more liability exposure through this alienation. We propose that by returning to an educational model, the patients will develop a greater sense of control, become more compliant, and potentially experience improved healthcare outcomes. There may also develop an alliance between the patient and the physician or surgeon, such that the seeds of an antagonistic or litigious relationship will not be planted before treatment begins. Liability reduction, therefore, may more likely arise from the educational model.

Twenty Years of Evidence on the Outcomes of Malpractice Claims

Philip G. Peters JD Two decades of social science research on the outcomes of medical malpractice claims show malpractice outcomes bear a surprisingly good correlation with the quality of care provided to the patient as judged by other physicians. Physicians win 80% to 90% of the jury trials with weak evidence of medical negligence, approximately 70% of the borderline cases, and even 50% of the trials in cases with strong evidence of medical negligence. With only one exception, all of the studies of malpractice settlements also find a correlation between the odds of a settlement payment and the quality of care provided to the plaintiff. Between 80% and 90% of the claims rated as defensible are dropped or dismissed without payment. In addition, the amount paid in settlement drops as the strength of the patient’s evidence weakens.

Surgeon Demographics and Medical Malpractice in Adult Reconstruction

Brian J. McGrory MD, B. Sonny Bal MD, MBA, Sally York MN, RNC, William Macaulay MD, David B. McConnell JD Orthopaedic adult reconstruction subspecialists are sued for alleged medical malpractice at a rate over twice that of the physician population as a whole, and the rate appears disproportionately high in the first decade of practice. The overall risk of a malpractice claim is related to years spent in practice. After 30 years in an adult reconstruction practice, the cumulative rate of being sued at least once is over 90%. Previous investigations suggest factors such as practice setting and size, fellowship training, years in practice, volume, and location of practice correlate with malpractice risk. In contrast, we were unable to identify any relationship between the type, size, or location of practice, fellowship training, or surgery volume and the risk of an adult reconstruction surgeon being named as a defendant in a malpractice suit.,[object Object]

Juries and Medical Malpractice Claims: Empirical Facts versus Myths

Neil Vidmar JD Juries in medical malpractice trials are viewed as incompetent, antidoctor, irresponsible in awarding damages to patients, and casting a threatening shadow over the settlement process. Several decades of systematic empirical research yields little support for these claims. This article summarizes those findings. Doctors win about three cases of four that go to trial. Juries are skeptical about inflated claims. Jury verdicts on negligence are roughly similar to assessments made by medical experts and judges. Damage awards tend to correlate positively with the severity of injury. There are defensible reasons for large damage awards. Moreover, the largest awards are typically settled for much less than the verdicts.

Apologies and Medical Error

Jennifer K. Robbennolt PhD, JD One way in which physicians can respond to a medical error is to apologize. Apologies—statements that acknowledge an error and its consequences, take responsibility, and communicate regret for having caused harm—can decrease blame, decrease anger, increase trust, and improve relationships. Importantly, apologies also have the potential to decrease the risk of a medical malpractice lawsuit and can help settle claims by patients. Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologize. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologizing after medical error, the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologizing for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error.

The Expert Witness in Medical Malpractice Litigation

B. Sonny Bal MD, MBA Physicians may find serving as an expert witness to be interesting, intellectually stimulating, and financially beneficial. However, potential expert witnesses should be aware of the increased legal scrutiny being applied to expert witness testimony in medical malpractice litigation. In the past, expert witnesses received absolute immunity from civil litigation regarding their testimony. This is no longer the case. Expert witnesses may be subject to disciplinary sanctions from professional organizations and state medical boards. In addition, emerging case law is defining the legal duty owed by the expert witness to the litigating parties. Orthopaedic surgeons who serve as expert witnesses should be familiar with the relevant Standards of Professionalism issued by the American Academy of Orthopaedic Surgeons.

Medical Liability Reform Crisis 2008

Stuart L. Weinstein MD The crisis of medical liability has resulted in drastic increases in insurance premiums and reduced access for patients to specialty care, particularly in areas such as obstetrics/gynecology, neurosurgery, and orthopaedic surgery. The current liability environment neither effectively compensates persons injured from medical negligence nor encourages addressing system errors to improve patient safety. The author reviews trends across the nation and reports on the efforts of an organization called “Doctors for Medical Liability Reform” to educate the public and lawmakers on the need for solutions to the chaotic process of adjudicating medical malpractice claims in the United States.

The Problem of the Aging Surgeon: When Surgeon Age Becomes a Surgical Risk Factor

Ralph B. Blasier MD, JD The question of when a surgeon should retire has been the subject of debate for decades. Both anecdotal evidence and objective testing of surgeons suggest age causes deterioration in physical and cognitive performance. Medical education, residency and fellowship training, and technology evolve at a rapid pace, and the older a surgeon is, the more likely it is he or she is remote from his or her initial education in his or her specialty. Research also shows surgeons are reluctant to plan for retirement. Although there is no federally mandated retirement age for surgeons in the United States, surgeons must realize their skills will decline, a properly planned retirement can be satisfying, and the retired surgeon has much to offer the medical and teaching community.

Medical Malpractice and the Sports Medicine Clinician

Steven M. Kane MD, Richard A. White MD More individuals are participating in athletics today than ever before. Physicians treating athletes confront unique diagnostic and treatment challenges and an increased risk of legal liability. The key areas regarding liability are preparticipation examinations, determination of eligibility, evaluation of significant on-field injuries, and information disclosure. The issues surrounding preparticipation physicals and determination of eligibility are closely linked. Physicians must be prepared to seek guidance from specialists, particularly when there are cardiac, spinal, or neurologic issues. Appropriate on-field evaluation of potential concussions, spinal injuries, and heat stroke are key areas of concern for the physician. Privacy issues have become more complex in the age of federal regulation. Physicians and all athletic staff should be aware of privacy laws and ensure proper consent documentation is obtained from all athletes or their parents. All athletic programs should develop a plan that details roles and procedures to be followed in a medical emergency. Sports caregivers must take affirmative steps that better protect their patients from harm and physicians from legal liability.

A Modified No-fault Malpractice System Can Resolve Multiple Healthcare System Deficiencies

Jeffrey J. Segal MD, FACS, Michael Sacopulos JD Medical professional liability in the United States, as measured by total premiums paid by physicians and healthcare facilities, costs approximately $30 billion a year in direct expenses, less than 2% of the entire annual healthcare expenditures. Only a fraction of those dollars reach patients who are negligently injured. Nonetheless, the tort system has far-reaching effects that create substantial indirect costs. Medical malpractice litigation is pervasive and physicians practice defensively to avoid being named in a suit. Those extra expenditures provide little value to patients. Despite an elaborate existing tort system, patient safety remains a vexing problem. Many injured patients are denied access to timely, reasonable remedies. We propose a no-fault system supplemented by a variation of the traditional tort system whereby physicians are incentivized to follow evidence-based guidelines. The proposed system would guarantee a substantial decrease in, but not elimination of, litigation. The system would lower professional liability premiums. Injured patients would ordinarily be compensated with no-fault disability and life insurance proceeds. To the extent individual physicians pose a recurrent danger, their care would be reviewed on an administrative level. Savings would be invested in health information technology and purchase of insurance coverage for the uninsured. We propose a financial model based on publicly accessible sources.

Limiting Exposure to Medical Malpractice Claims and Defamatory Cyber Postings via Patient Contracts

Michael Sacopulos JD, Jeffrey J. Segal The documents patients sign on admission to a medical practice can constitute a legal contract. Medical practices around the country are attempting to use these documents as a prospective defense against medical malpractice claims. Protective contractual provisions are often attacked on grounds that they are legally void as a result of unconscionability. Widespread use of arbitration clauses have been met with mixed success. Arbitration clauses that limit damages available in medical negligence cases have been stricken in some states as having provisions that impose excessive entry costs on a patient starting the arbitration process. Other provisions relating to prequalification requirements for expert witnesses are now being used with increasing frequency. Clauses have even been placed in patient contracts that address cyber postings of adverse claims against physicians. Prospective patient contracts may be an effective means to limit exposure to medical malpractice lawsuits and to minimize defamatory cyber postings.

Medical Malpractice: The Experience in Italy

Francesco Traina MD At the present time, legal actions against physicians in Italy number about 15,000 per year, and hospitals spend over €10 billion (~US$15.5 billion) to compensate patients injured from therapeutic and diagnostic errors. In a survey summary issued by the Italian Court for the Rights of the Patient, between 1996 and 2000 orthopaedic surgery was the highest-ranked specialty for the number of complaints alleging medical malpractice. Today among European countries, Italy has the highest number of physicians subject to criminal proceedings related to medical malpractice, a fact that is profoundly changing physicians’ approach to medical practice. The national health system has paid increasingly higher insurance premiums and is having difficulty finding insurance companies willing to bear the risk of monetary claims alleging medical malpractice. Healthcare costs will likely worsen as Italian physicians increasingly practice defensive medicine, thereby overutilizing resources with the goal of documenting diligence, prudence, and skill as defenses against potential litigation, rather than aimed at any patient benefit. To reduce the practice of defensive medicine and healthcare costs, a possible solution could be the introduction of an extrajudicial litigation resolution, as in other civil law countries, and a reform of the Italian judicial system on matters of medical malpractice litigation.

The Regulation of Medical Malpractice in Japan

Robert B Leflar JD, MPH How Japanese legal and social institutions handle medical errors is little known outside Japan. For almost all of the 20th century, a paternalistic paradigm prevailed. Characteristics of the legal environment affecting Japanese medicine included few attorneys handling medical cases, low litigation rates, long delays, predictable damage awards, and low-cost malpractice insurance. However, transparency principles have gained traction and public concern over medical errors has intensified. Recent legal developments include courts’ adoption of a less deferential standard of informed consent; increases in the numbers of malpractice claims and of practicing attorneys; more efficient claims handling by specialist judges and speedier trials; and highly publicized criminal prosecutions of medical personnel. The health ministry is undertaking a noteworthy “model project” to enlist impartial specialists in investigation and analysis of possible iatrogenic hospital deaths to regain public trust in medicine’s capacity to assess its mistakes honestly and to improve patient safety and has proposed a nationwide peer review system based on the project’s methods.

Indications for Surgery in Clinical Outcome Studies of Rotator Cuff Repair

Robert G. Marx MD, MSc, FRCSC, Panagiotis Koulouvaris MD, PhD, Samuel K. Chu BA, Bruce A. Levy MD Full-thickness tears of the rotator cuff are common, but there is no clear consensus regarding indications for rotator cuff surgery. Because some patients with full-thickness rotator cuff tears who are asymptomatic or symptomatic can be successfully treated nonoperatively, clinical outcome studies of rotator cuff repair should describe the subjects in detail to allow appropriate interpretation of the results. However, we hypothesized the indications for surgery are poorly described in outcome studies of rotator cuff surgery. We undertook a detailed literature review over 11 years of six major orthopaedic journals to assess whether the indications for surgery were described adequately in studies of rotator cuff repair. Eighty-six papers fit the criteria for the study and were reviewed. Limitations of activities of daily living (31%), failure of nonoperative treatment (52%), duration of nonoperative treatment (26%), and history of nocturnal pain (16%) were reported in a minority of papers overall. The patients’ characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. It is important for these factors to be considered and reported because, without this information, the reasons for and results of rotator cuff repair are difficult to interpret.,[object Object]

Expression of Atrophy mRNA Relates to Tendon Tear Size in Supraspinatus Muscle

Silvia Schmutz PhD, Thomas Fuchs, Felix Regenfelder MD, Patrick Steinmann MD, M. Zumstein MD, Bruno Fuchs MD, PhD Skeletal muscle atrophy and fatty infiltration develop after tendon tearing. The extent of atrophy serves as one prognostic factor for the outcome of surgical repair of rotator cuff tendon tears. We asked whether mRNA of genes involved in regulation of degradative processes leading to muscle atrophy, ie, FOXOs, MSTN, calpains, cathepsins, and transcripts of the ubiquitin-proteasome pathway, are overexpressed in the supraspinatus muscle in patients with and without rotator cuff tears. We evaluated biopsy specimens collected during surgery of 53 consecutive patients with different sizes of rotator cuff tendon tears and six without tears. The levels of corresponding gene transcripts in total RNA extracts were assessed by semiquantitative reverse transcriptase-polymerase chain reaction (RT-PCR) analysis. Supraspinatus muscle atrophy was assessed by MRI. The area of muscle tissue (or atrophy), decreased (increased) with increasing tendon tear size. The transcripts of CAPN1, UBE2B, and UBE3A were upregulated more than twofold in massive rotator cuff tears as opposed to smaller tears or patients without tears. These atrophy gene products may be involved in cellular processes that impair functional recovery of affected muscles after surgical rotator cuff repair. However, the damaging effects of gene products in their respective proteolytic processes on muscle structures and proteins remains to be investigated.

Use of a Dual Mobility Socket to Manage Total Hip Arthroplasty Instability

Olivier Guyen MD, PhD, Vincent Pibarot MD, Gualter Vaz MD, Christophe Chevillotte MD, Jacques Béjui-Hugues MD Unconstrained tripolar hip implants provide an additional bearing using a mobile polyethylene component between the prosthetic head and the outer metal shell. Such a design increases the effective head diameter and therefore is an attractive option in challenging situations of unstable total hip arthroplasties. We report our experience with 54 patients treated using this dual mobility implant in such situations. We ascertained its ability to restore and maintain stability, and examined component loosening and component failure. At a minimum followup of 2.2 years (mean, 4 years; range, 2.2–6.8 years), one hip had redislocated 2 months postoperatively and was managed successfully without reoperation by closed reduction with no additional dislocation. Two patients required revision of the implant because of dislocation at the inner bearing. Technical errors were responsible for these failures. Three patients had reoperations for deep infections. The postoperative radiographs at latest followup showed very satisfactory osseointegration of the acetabular component because no radiolucent line or osteolysis was reported. Use of this unconstrained tripolar design was successful in restoring and maintaining hip stability. We observed encouraging results at short-term followup regarding potential for loosening or mechanical failures.,[object Object]

Which Approach for Total Hip Arthroplasty: Anterolateral or Posterior?

Jeya Palan MRCS (Eng), David J. Beard DPhil, David W. Murray FRCS (Orth), J. G. Andrew FRCS (Orth), John Nolan FRCS (Orth) The best approach to use when performing THA is controversial. We did a prospective, nonrandomized multicenter study of 1089 THAs to evaluate patient-centered hip scores and dislocation and revision rates when comparing anterolateral and posterior hip approaches at 5 years’ followup. Patients were divided into two groups depending on which surgical approach was used: anterolateral or posterior. The primary outcome measure was change in Oxford hip score. At 5 years, there were no differences in change in Oxford hip score and in dislocation or revision rates between the groups.,[object Object]

Bone Remodeling and Hydroxyapatite Resorption in Coated Primary Hip Prostheses

Alphons J. Tonino MD, PhD, Bart C. H. Wal MD, Ide C. Heyligers MD, PhD, Bernd Grimm PhD Hydroxyapatite coatings for THA promote bone ongrowth, but bone and coating are exposed to stress shielding-driven osteoclastic resorption. We asked: (1) if the resorption of hydroxyapatite coating and bone ongrowth correlated with demographics; (2) if the resorption related to the stem level; and (3) what happens to the implant-bone interface when all hydroxyapatite coating is resorbed? We recovered 13 femoral components from cadaveric specimens 3.3 to 11.2 years after uneventful primary THA. Three cross sections (proximal, medial, distal) of the hydroxyapatite-coated proximal implant sleeve were analyzed by measuring the percentage of residual hydroxyapatite and bone ongrowth on the implant perimeter. Hydroxyapatite resorption was independent of patient age but increased with time in vivo and mostly was gone after 8 years. Bone ongrowth was independent of time in vivo but decreased with aging patients. Only in the most proximal section did less residual hydroxyapatite correlate with less bone ongrowth. Hydroxyapatite resorption, which was more proximal than distal, showed no adverse effects on the implant-bone interface.

Distal Femoral Replacement in Nontumor Cases with Severe Bone Loss and Instability

Keith R. Berend MD, Adolph V. Lombardi MD, FACS Severe distal femoral bone loss and instability in revision TKA is challenging. We retrospectively reviewed 39 rotating-hinged distal femoral replacement devices in 37 patients to examine whether improved results were obtainable, using one design, over previously published results. The average age of the patients was 76 years (standard deviation, 10 years). Indications for distal femoral replacement included 11 revision TKAs, 13 periprosthetic fractures, 11 reimplantations, two complex primary TKAs, one distal femoral nonunion, and one acute distal femur fracture. Minimum followup was 24 months (mean, 46 months; range, 24–109 months). Eight patients died during followup. There were five reoperations: two patients with recurrent infection after two-stage treatment, one patient with a periprosthetic fracture treated by open reduction and internal fixation, one patient with late hematogenous infection, and one patient with bearing exchange to treat hyperextension. No failures from aseptic loosening were seen. Knee Society scores improved from 39 preoperatively to 87, and pain scores improved from 18 preoperatively to 43. Distal femoral prosthetic replacement with a tumor-type implant in severe cases provides excellent pain relief and function with a low short-term reoperation rate and an implant survivorship rate of 87% at 46 months.,[object Object]

Early Outcome of TKA with a Medial Pivot Fixed-bearing Prosthesis is Worse than with a PFC Mobile-bearing Prosthesis

Young-Hoo Kim MD, Sung-Hwan Yoon MD, Jun-Shik Kim MD Although the design features of the Medial Pivot fixed-bearing prosthesis reportedly improve kinematics compared with TKAs using fixed-bearings, clinical improvements have not been reported. We asked whether the clinical and radiographic outcomes, ranges of motion of the knee, patient satisfaction, and complication rates would be better in knees with a Medial Pivot fixed-bearing prosthesis than in those with a PFC Sigma mobile-bearing prosthesis. We compared the results of 92 patients who had a Medial Pivot fixed-bearing prosthesis implanted in one knee and a PFC Sigma mobile-bearing prosthesis implanted in the other. There were 85 women and seven men with a mean age of 69.5 years (range, 55–81 years). The minimum followup was 2 years (mean, 2.6 years; range, 2–3 years). The patients were assessed clinically and radiographically using the rating systems of the Hospital for Special Surgery and the Knee Society at 3 months, 1 year, and annually thereafter. Contrary to expectations, we found worse early clinical outcomes, smaller ranges of knee motion, less patient satisfaction, and a higher complication rate for the Medial Pivot fixed-bearing prosthesis than for the PFC Sigma mobile-bearing prosthesis.,[object Object]

Frontal Knee Alignment: Three-dimensional Marker Positions and Clinical Assessment

Benedicte Vanwanseele PhD, David Parker MD, Myles Coolican MD We assessed the validity of the hip-knee-ankle angle measured statically during three-dimensional (3-D) gait analysis and the tibial angle using an inclinometer compared with the mechanical axis on radiographs. Eleven individuals (20 knees) with radiographic knee osteoarthritis (OA) participated in this study. We determined the following: the lower-limb mechanical axis using weightbearing long-leg radiographs; hip-knee-ankle angle using the techniques of 3-D gait analysis in a static standing position; and tibial alignment using an inclinometer. The mean mechanical axis (± standard deviation) for this cohort was 0.7° ± 7.2° (range, −13°−16°). The tibial alignment and hip-knee-ankle angle correlated with the mechanical axis but the correlation between the mechanical axis and the hip-knee-ankle angle was stronger. Our data suggest the inclinometer and 3-D gait analysis are valid ways to estimate mechanical alignment of the knee.

Osteosarcoma of the Pelvis: Outcome Analysis of Surgical Treatment

Bruno Fuchs MD, PhD, Nathan Hoekzema MD, Dirk R. Larson MS, Carrie Y. Inwards MD, Franklin H. Sim MD Risk factors to explain the poor survival of patients with osteosarcoma of the pelvis are poorly understood. Therefore, we attempted to identify factors affecting survival and development of local recurrence and metastasis. We retrospectively reviewed 43 patients who had high-grade pelvic tumors and were treated surgically. Twenty lesions were chondroblastic, 10 fibroblastic, 11 osteoblastic, and one each was giant cell-rich and small cell osteosarcomas. At a median of 3.5 years (range, 0.3–21 years) postoperatively, 13 patients were alive with no evidence of disease. The overall and disease-free 5-year survival rates were 38% and 29%, respectively, at 5 years. Anatomic location, tumor size, and margin predicted survival. Fifteen patients (35%) had local recurrence. The 5-year cumulative incidence of recurrence with death as a competing risk factor was 34%. Location in the ilium and size of the tumor predicted local recurrence. Twenty-one (49%) of 43 patients had metastases develop. The cumulative incidence of metastasis with death as a competing risk factor was 48% at 5 years. Six patients who presented with metastasis had a worse survival than patients who had no evidence of metastasis at presentation (2-year survival, 33% versus 76%). If distant metastasis is diagnosed subsequent to primary treatment, aggressive therapy may be justified.,[object Object]

Consequences and Prevention of Inadvertent Internal Fixation of Primary Osseous Sarcomas

Sheila Conway Adams MD, Benjamin K. Potter MD, Zakariah Mahmood MD, J. David Pitcher MD, H. Thomas Temple MD The evaluation and treatment of aggressive bone tumors continue to be diagnostic and therapeutic challenges for orthopaedic surgeons. Despite compelling data regarding the hazards of biopsy, incomplete preoperative evaluation, inappropriate biopsy techniques, and premature surgical interventions continue to compromise optimal treatment of primary bone sarcomas. We retrospectively identified eight patients who had internal fixation of a primary bone sarcoma before referral to an orthopaedic oncology service. Six of the eight patients subsequently underwent amputations and two patients underwent limb salvage for local disease control. Biopsy techniques from referring institutions were highly variable, with only two of seven rendering an accurate diagnosis. The average Musculoskeletal Tumor Society functional score was 10.6 and four of eight patients were disease-free and alive at a minimum followup of 8 months (mean, 26.9 months; range, 8–80 months). Implant violation of primary bone malignancies was associated with frequent high-level amputation for local disease control and low Musculoskeletal Tumor Society functional scores. Common errors in the initial evaluation and treatment included inadequate attention to patient history, incomplete radiographic evaluation, and improper biopsy and surgical techniques, which violated compartmental boundaries.,[object Object]

A Superficial Swab Culture is Useful for Microbiologic Diagnosis in Acute Prosthetic Joint Infections

Jordi Cuñé MD, Alex Soriano PhD, Juan C. Martínez MD, Sebastián García PhD, Josep Mensa MD The literature documents poor concordance between superficial swab and intraoperative tissue cultures in chronic prosthetic joint infections but is less clear in acute postsurgical prosthetic joint infections. We evaluated the relationship between superficial swab and deep intraoperative cultures in 56 patients with acute postsurgical prosthetic joint infections from June 2003 to June 2007; patients receiving antibiotics were excluded. There were 30 hip and 26 knee prostheses. A superficial sample of the wound drainage was taken at admission and three deep samples were obtained during open débridement. Concordance was defined when at least one of the microorganisms isolated in the superficial samples also was found in the deep samples. The analysis also was performed according to the type of microorganism: Staphylococcus aureus, gram-negative bacilli, or other gram-positive microorganisms. Concordance between superficial and deep samples was 80.3% (45 of 56). The sensitivity, specificity, and positive and negative predictive values of superficial cultures to predict the microorganism isolated in deep cultures varied depending on the type of microorganism: 93.7%, 100%, 100%, and 97.5% for S. aureus; 90%, 91.6%, 85.7%, and 94.3% for gram-negative bacilli; and 50%, 75%, 60%, and 66.7% for other gram-positive microorganisms. We therefore believe the superficial swab culture is useful in identifying the etiologic microorganism of acute prosthetic joint infections, especially when S. aureus or gram-negative bacilli were identified.,[object Object]

The Influence of Maggot Excretions on PAO1 Biofilm Formation on Different Biomaterials

Gwendolyn Cazander MD, Kiril E. B. Veen, Lee H. Bouwman MD, PhD, Alexandra T. Bernards MD, PhD, Gerrolt N. Jukema MD, PhD Biofilm formation in wounds and on biomaterials is increasingly recognized as a problem. It therefore is important to focus on new strategies for eradicating severe biofilm-associated infections. The beneficial effects of maggots (Lucilia sericata) in wounds have been known for centuries. We hypothesized sterile maggot excretions and secretions (ES) could prevent, inhibit, and break down biofilms of Pseudomonas aeruginosa (PAO1) on different biomaterials. Therefore, we investigated biofilm formation on polyethylene, titanium, and stainless steel. Furthermore, we compared the biofilm reduction capacity of Instar-1 and Instar-3 maggot ES and tested the temperature tolerance of ES. After biofilms formed in M63 nutrient medium on comb-forming models of the biomaterials, ES solutions in phosphate-buffered saline or M63 were added in different concentrations. PAO1 biofilms adhered tightly to polyethylene and titanium but weakly to stainless steel. Maggot ES prevent and inhibit PAO1 biofilm formation and even break down existing biofilms. ES still had considerable biofilm reduction properties after storage at room temperature for 1 month. ES from Instar-3 maggots were more effective than ES from Instar-1 maggots. These results may be relevant to patient care as biofilms complicate the treatment of infections associated with orthopaedic implants.

Evaluation of Skills in Arthroscopic Training Based on Trajectory and Force Data

Yasutaka Tashiro MD, Hiromasa Miura MD, PhD, Yoshitaka Nakanishi PhD, Ken Okazaki MD, PhD, Yukihide Iwamoto MD, PhD [object Object]

Recognizing and Preventing Burnout among Orthopaedic Leaders

Khaled J. Saleh MD, MSc, FRCSC, FACS, James Campbell Quick, Wesley E. Sime, Wendy M. Novicoff PhD, Thomas A. Einhorn MD Stress, emotional exhaustion, and burnout are widespread in the medical profession in general and in orthopaedic surgery in particular. We attempted to identify variables associated with burnout as assessed by validated instruments. Surveys were sent to 282 leaders from orthopaedic surgery academic departments in the United States by e-mail and mail. Responses were received from 195 leaders for a response rate of 69%. The average surgeon worked 68.3 hours per week and more than ½ of this time was allocated to patient care. Highest stressors included excessive workload, increasing overhead, departmental budget deficits, tenure and promotion, disputes with the dean, and loss of key faculty. Personal-professional life imbalance was identified as an important risk factor for emotional exhaustion. Withdrawal, irritability, and family disagreements are early warning indicators of burnout and emotional exhaustion. Orthopaedic leaders can learn, and potentially model, ways to mitigate stress from other high-stress professions. Building on the strength of marital and family bonds, improving stress management skills and self-regulation, and improving efficiency and productivity can combine to assist the orthopaedic surgery leader in preventing burnout and emotional exhaustion.

Case Report: Patella Baja After Retrograde Femoral Nail Insertion

James C. Krieg MD, Amer Mirza MD Patella baja is a rare condition that can result from conditions involving trauma around the knee. Risk factors are believed to include scar tissue formation in the retropatellar fat pad, extensor mechanism dysfunction, and immobilization in extension. Early recognition and aggressive treatment are critical components in minimizing long-term disability. We present a case report of a woman with a fracture of the femoral diaphysis who underwent retrograde placement of an intramedullary nail. Subsequent followup revealed development of patella baja with resultant disability. The diagnosis was made late and the treatment was ineffective. Although patella baja has been reported in trauma around the knee, causative factors include retrograde femoral nailing. We believe early recognition and institution of treatment are important.

Case Report: Reconstruction of a 16-cm Diaphyseal Defect after Ewing’s Resection in a Child

David Jean Biau MD, Stéphanie Pannier MD, Alain Charles Masquelet MD, Christophe Glorion MD Numerous options exist for intercalary segmental reconstruction after bone tumor resection. We present the extension of a recently developed surgical two-stage technique that involves insertion of a cement spacer, induction of a membrane, and reconstruction of the defect with cancellous and cortical bone autograft in a 12-year-old child. The boy was referred to our center for treatment of a right femoral diaphyseal Ewing’s sarcoma. The first stage involved resection of the tumor and reconstruction with a locked intramedullary nail and a polymethylmethacrylate cement spacer. Seven months after the initial procedure during which adjuvant chemotherapy was given, the second-stage procedure was performed. The cement was removed and cancellous and cortical bone autograft was grafted in the membrane created around the cement spacer. Touchdown weightbearing was allowed immediately, partial weightbearing was resumed 6 weeks after the operation, and full weightbearing was allowed 4 months later. Successive plain radiographs showed rapid integration of the autograft to the host bone with bone union and cortical reconstitution. The principle of the induced membrane reconstruction seems applicable to intercalary segmental reconstruction after bone tumor resection in children.

Erratum: The Female Knee: Anatomic Variations and the Female-specific Total Knee Design

Alan C. Merchant MD, Elizabeth A. Arendt MD, Scott F. Dye MD, Michael Fredericson MD, Ronald P. Grelsamer MD, Wayne B. Leadbetter MD, William R. Post MD, Robert A. Teitge MD

Erratum: Initial American Experience with Hip Resurfacing Following FDA Approval

Craig J. Della Valle MD, Ryan M. Nunley MD, Stephen J. Raterman MD, Robert L. Barrack MD

Low Backache in a 70-year-old Woman

Aditya V. Maheshwari MD, Jeremy S. Frank MD, J. David Pitcher MD, H. Thomas Temple MD
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