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Bruinsma W.E.,University of Groningen | Becker S.J.E.,Massachusetts General Hospital | Guitton T.G.,Orthopaedic Research Center Amsterdam | Kadzielski J.,South Shore Orthopedics | Ring D.,Harvard University
Clinical Orthopaedics and Related Research | Year: 2015

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. © 2014, The Association of Bone and Joint Surgeons®.


Bruinsma W.E.,Trauma Unit | Guitton T.,Orthopaedic Research Center Amsterdam | Ring D.,Massachusetts General Hospital
Clinical Orthopaedics and Related Research | Year: 2014

Background: Loss of contact between radial head fracture fragments is strongly associated with other elbow or forearm injuries. If this finding has adequate interobserver reliability, it could help examiners identify and treat associated ligament injuries and fractures (eg, forearm interosseous ligament injury or elbow dislocation). Questions/purposes: (1) What is the interobserver agreement on radiographic loss of contact between radial head fracture fragments? (2) Are there factors associated with the observer such as location of practice or subspecialization that increase interobserver reliability? Methods: Fully trained practicing orthopaedic and trauma surgeons from around the world evaluated 27 anteroposterior and lateral radiographs of radial head fractures on a web-based platform for the following characteristics: (1) loss of contact between at least one radial head fracture fragment and the remaining radial head and neck; (2) a gap between fragments of 2 mm or greater; (3) anticipated fracture instability (mobility) on operative exposure; (4) anticipated associated ligament injuries; and (5) recommendation for treatment. Agreement among observers was measured using the multirater kappa measure. Kappas for various observer characteristics were compared using 95% confidence intervals. Results: The overall interobserver agreement was moderate (range, 0.49-0.55) for each question except associated ligament injury, which was fair (0.33). Shoulder and elbow surgeons had substantial agreement (range, 0.51-0.61) in many areas, but kappas were generally in the moderate range (0.41-0.59) based on number of years in practice, radial head fractures treated per year, and trainee supervision. Conclusions: Radiographic signs of radial head fracture instability such as loss of contact have moderate reliability. This characteristic seems clinically useful, because loss of contact between at least one radial head fracture fragment and the remaining radial head and neck is strongly associated with associated ligament injury or other fractures. Level of Evidence: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence. © 2014 The Association of Bone and Joint Surgeons®.


van Eck C.F.,University of Pittsburgh | van Eck C.F.,Orthopaedic Research Center Amsterdam | Schreiber V.M.,University of Pittsburgh | Liu T.T.,University of Pittsburgh | Fu F.H.,University of Pittsburgh
Knee Surgery, Sports Traumatology, Arthroscopy | Year: 2010

The anatomic approach is gaining popularity in anterior cruciate ligament (ACL) reconstruction. It is predominantly applied during primary ACL reconstruction. However, following the same principles as during primary surgery, the anatomic approach can also be applied during revision and augmentation surgery. This paper discusses the surgical technique for anatomic single- and double-bundle ACL reconstruction, for primary, revision and augmentation surgery. During primary reconstruction, the choice for single- or double-bundle reconstruction and graft size should be based on ACL insertion site and femoral intercondylar notch dimensions. When there is an isolated anteromedial (AM) or posterolateral (PL) bundle rupture, augmentation of a single-bundle can be performed while protecting the integrity of the intact bundle. Especially during revision surgery, there are many potential situations the surgeon may encounter when entering the knee. There are multiple possible solutions for all of these different situations leading to an anatomic end result. Three-dimensional computed tomography (CT) scanning should be used to evaluate the current tunnel positions and determine the operative strategy. © 2010 Springer-Verlag.


van Eck C.F.,University of Pittsburgh | van Eck C.F.,Orthopaedic Research Center Amsterdam | van den Bekerom M.P.J.,Orthopaedic Research Center Amsterdam | Fu F.H.,University of Pittsburgh | And 2 more authors.
Knee Surgery, Sports Traumatology, Arthroscopy | Year: 2013

Purpose: The aims of this meta-analysis were to determine the sensitivity and specificity of the Lachman, pivot shift and anterior drawer test for acute complete ACL rupture in the office setting and under anaesthesia. It was hypothesized that the Lachman test is the most sensitive and the pivot shift test the most specific. Secondly, it was hypothesized that the sensitivity and specificity of all three exams increases when the examination is performed under anaesthesia. Methods: An electronic database search was performed using MEDLINE and EMBASE. All cross-sectional and cohort studies comparing one or more physical examination tests for diagnosing acute complete ACL rupture to an accepted reference standard such as arthroscopy, arthrotomy and MRI were included. Results: Twenty studies were identified and included. The overall sensitivity of the Lachman test was 0.81 and the specificity 0.81; with anaesthesia, the sensitivity was 0.91 and the specificity 0.78. For the anterior drawer test, the sensitivity was 0.38 and the specificity 0.81; with anaesthesia, the sensitivity was 0.63 and the specificity 0.91. The sensitivity of the pivot shift test was 0.28 and the specificity 0.81; with anaesthesia, the sensitivity was 0.73 and the specificity 0.98. Conclusion: In the office setting, the Lachman test has the highest sensitivity for diagnosing an acute, complete ACL rupture, while all three tests had comparable specificity. When the examination was performed under anaesthesia, the Lachman test still obtained the highest sensitivity, but the pivot shift test was the most specific. Level of evidence: Meta-analysis of diagnostic test accuracy, Level II. © 2012 Springer-Verlag Berlin Heidelberg.


van Eck C.F.,University of Pittsburgh | van Eck C.F.,Orthopaedic Research Center Amsterdam | Lesniak B.P.,University of Pittsburgh | Schreiber V.M.,University of Pittsburgh | Fu F.H.,University of Pittsburgh
Arthroscopy - Journal of Arthroscopic and Related Surgery | Year: 2010

Anatomy is the foundation of orthopaedic surgery, and the advancing knowledge of the anterior cruciate ligament (ACL) anatomy has led to the development of improved modern reconstruction techniques that approach the anatomy of the native ACL. Current literature on the anatomy of the ACL and its reconstruction techniques, as well as our surgical experience, was used to develop a flowchart that can aid the surgeon in performing anatomic ACL reconstruction. We define anatomic ACL reconstruction as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites. A guideline was written to accompany this flowchart with more detailed information on anatomic ACL reconstruction and its pitfalls, all accompanied by relevant literature and helpful figures. Although there is still much to learn about anatomic ACL reconstruction methods, we believe this is a helpful document for surgeons. We continue to modify the flowchart as more information about the anatomy of the ACL, and how to more closely reproduce it, becomes available. © 2010 Arthroscopy Association of North America.


Muller B.,University of Pittsburgh | Muller B.,Orthopaedic Research Center Amsterdam | Bowman K.F.,University of Pittsburgh | Bedi A.,University of Michigan
Clinics in Sports Medicine | Year: 2013

Operative reconstruction of a torn anterior cruciate ligament (ACL) has become the most broadly accepted treatment. An important, but underreported, outcome of ACL reconstruction is graft failure, which poses a challenge for the orthopedic surgeon. An understanding of the tendon-bone healing and the intra-articular ligamentization process is crucial for orthopedic surgeons to make appropriate graft choices and to be able to initiate optimal rehabilitation protocols after surgical ACL reconstruction. This article focuses on the current understanding of the tendon-to-bone healing process for both autografts and allografts and discusses strategies to biologically augment healing. © 2013 Elsevier Inc.


Schreiber V.M.,University of Pittsburgh | Van Eck C.F.,Orthopaedic Research Center Amsterdam | Fu F.H.,University of Pittsburgh
Sports Medicine and Arthroscopy Review | Year: 2010

Rupture of the anterior cruciate ligament (ACL) is one of the most frequent forms of knee trauma. The traditional surgical treatment for ACL rupture is single-bundle reconstruction. However, during the past few years there has been a shift in interest toward double-bundle reconstruction to closely restore the native ACL anatomy. This paper evaluates the basis for double-bundle ACL reconstruction including anatomy, biomechanics and kinematics, describes our surgical technique, and discusses why we prefer anatomic double-bundle ACL reconstruction, as well as its outcome, the choices, and the controversies of double-bundle ACL reconstruction. Pitfalls of traditional ACL surgery are also discussed, the recognition of which is the key to performing anatomic ACL reconstruction. © 2010 Lippincott Williams & Wilkins, Inc.


van den Bekerom M.P.J.,Orthopaedic Research Center Amsterdam | Kerkhoffs G.M.M.J.,Orthopaedic Research Center Amsterdam | McCollum G.A.,Chelsea and Westminister Hospital | McCollum G.A.,The London Clinic | And 3 more authors.
Knee Surgery, Sports Traumatology, Arthroscopy | Year: 2013

Purpose: Inversion injuries involve about 25 % of all injuries of the musculoskeletal system and about 50 % of these injuries are sport-related. This article reviews the acute lateral ankle injuries with special emphasis on a rationale for treatment of these injuries in athletes. Methods: A narrative review was performed using Pubmed/Medline, Ovid and Embase using key words: ankle ligaments, injury, lateral ligament, ankle sprain and athlete. Articles related to the topic were included and reviewed. Results: It is estimated that one inversion injury of the ankle occurs for every 10,000 people each day. Ankle sprains constitute 7-10 % of all admissions to hospital emergency departments. Inversion injuries involve about 25 % of all injuries of the musculoskeletal system, and about 50 % of these injuries are sport-related. The lateral ankle ligament complex consists of three ligaments: the anterior talofibular ligament, the calcaneofibular ligament and the posterior talofibular ligament. The most common trauma mechanism is supination and adduction (inversion) of the plantar-flexed foot. Conclusion: Delayed physical examination provides a more accurate diagnosis. Ultrasound and MRI can be useful in diagnosing associated injury and are routine investigations in professional athletes. Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, non-operative measures. RICE therapy is the treatment of choice for the first 4-5 days to reduce pain and swelling. Initially, 10-14 days of immobilization in a below the knee cast/brace is beneficial followed by a period in a lace-up brace or functional taping reduces the risk of recurrent injury. Acute repair of the lateral ankle ligaments in grade III injuries in professional athletes may give better results. Level of evidence: IV. © 2012 Springer-Verlag Berlin Heidelberg.


Buijze G.A.,Orthopaedic Research Center Amsterdam | Guitton T.G.,Orthopaedic Research Center Amsterdam | Van Dijk C.N.,Orthopaedic Research Center Amsterdam | Ring D.,Harvard University
Clinical Orthopaedics and Related Research | Year: 2012

Background The diagnosis of displacement in scaphoid fractures is notorious for poor interobserver reliability. Questions/purposes We tested whether training can improve interobserver reliability and sensitivity, specificity, and accuracy for the diagnosis of scaphoid fracture displacement on radiographs and CT scans. Methods Sixty-four orthopaedic surgeons rated a set of radiographs and CT scans of 10 displaced and 10 nondisplaced scaphoid fractures for the presence of displacement, using a web-based rating application. Before rating, observers were randomized to a training group (34 observers) and a nontraining group (30 observers). The training group received an online training module before the rating session, and the nontraining group did not. Interobserver reliability for training and nontraining was assessed by Siegel's multirater kappa and the Z-test was used to test for significance. Results There was a small, but significant difference in the interobserver reliability for displacement ratings in favor of the training group compared with the nontraining group. Ratings of radiographs and CT scans combined resulted in moderate agreement for both groups. The average sensitivity, specificity, and accuracy of diagnosing displacement of scaphoid fractures were, respectively, 83%, 85%, and 84% for the nontraining group and 87%, 86%, and 87% for the training group. Assuming a 5% prevalence of fracture displacement, the positive predictive value was 0.23 in the nontraining group and 0.25 in the training group. The negative predictive value was 0.99 in both groups. Conclusions Our results suggest training can improve interobserver reliability and sensitivity, specificity and accuracy for the diagnosis of scaphoid fracture displacement, but the improvements are slight. These findings are encouraging for future research regarding interobserver variation and how to reduce it further. © The Association of Bone and Joint Surgeons® 2012.

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