Oleg Safir - Academia.edu (original) (raw)

Papers by Oleg Safir

Research paper thumbnail of Risk factors for subsidence of a modular tapered femoral stem used for revision total hip arthroplasty

The Journal of Arthroplasty, 2015

The purpose of this study was to determine the incidence, and the clinical and radiographic risk ... more The purpose of this study was to determine the incidence, and the clinical and radiographic risk factors for significant subsidence of a cementless, modular tapered revision femoral stem. Femoral stem subsidence of at least 10 mm or subsidence requiring revision was considered significant subsidence. Ninety-seven patients (99 hips) were included with minimum radiographic follow-up of one year (mean 34 months; range, 12-91 months). The mean stem subsidence was 4.5 mm (range, 0-44 mm). Fourteen out of 99 (14.1%) stems had significant subsidence and 6 (6.1%) stems required revision due to subsidence. Patient weight greater than 80 kg (P=0.04) and femoral stem press-fit distance of less than 2 cm (P<0.01) were both independent risk factors for significant stem subsidence.

Research paper thumbnail of The Outcome of Modified Extended Trochanteric Osteotomy in Revision THA for Vancouver B2/B3 Periprosthetic Fractures of the Femur

The Journal of Arthroplasty, 2014

We hypothesised that a modified ETO in patients undergoing revision total hip arthroplasty (THA) ... more We hypothesised that a modified ETO in patients undergoing revision total hip arthroplasty (THA) for treatment of Vancouver B2/B3 peri-prosthetic fractures would be associated with good clinical outcomes. A retrospective review was conducted of 34 patients (mean age 73 years). At mean follow-up of 57 months, the ETO had healed in all patients. Two patients had subsidence of the femoral stem at two and three years postoperatively requiring revision, and one patient had a dislocation 3 months after surgery. The mean Harris Hip Score at the time of the final follow-up was 76.9 (range, 46-95); 23/34 patients had an excellent result, 7/34 a good result, and 4/34 a poor result. We conclude that satisfactory outcomes can be obtained using this technique.

Research paper thumbnail of Long-Term Follow-Up of Distal Femoral Varus Osteotomy of the Knee

Journal of Arthroplasty, 2007

Distal femoral varus osteotomy (DFVO) of the knee may be indicated for young, active patients wit... more Distal femoral varus osteotomy (DFVO) of the knee may be indicated for young, active patients with unicompartmental arthritis and valgus deformity. We report on 40 DFVOs with a mean follow-up of 123 months. At the most recent follow-up, 24 knees had good or excellent results (60%), 3 had fair results (7.5%), and 3 had poor results (7.5%). Four in the

Research paper thumbnail of Management of bone loss: structural grafts in revision total knee arthroplasty

Clinical orthopaedics and related research, 2006

Massive bone defects are challenging problems in revision knee surgery. When defects are large an... more Massive bone defects are challenging problems in revision knee surgery. When defects are large and uncontained (without a cortical rim), structural allografts may be used to provide support for femoral and tibial components. This study reviewed 68 structural allografts at a mean of 5.4 years for clinical and radiographic outcomes. Indications for grafts included periprosthetic fracture in 19 knees, aseptic loosening in 29, infection in 11 and instability in 2. Seven knees had both femoral and tibial allografts. Multiple implant designs were used including 7 hinged prostheses. Thirteen knees (13/61) failed due to graft related complications including one graft nonunion, three aseptic loosenings, three periprosthetic fractures, four infections, and two for instability. The case of graft nonunion was successfully treated with revision fixation and autologous bone graft. There were three cases of graft resorption, two graded as severe and one as moderate. These results are satisfactory ...

Research paper thumbnail of Distal Femoral Fresh Osteochondral Allografts: Follow-up at a Mean of Twenty-two Years

The Journal of bone and joint surgery. American volume, Jan 2, 2014

Osteochondral defects of the knee in young, active patients represent a challenge to the orthopae... more Osteochondral defects of the knee in young, active patients represent a challenge to the orthopaedic surgeon. Our study examined long-term outcomes of the use of fresh allograft for posttraumatic osteochondral and osteochondritis dissecans defects in the distal aspect of the femur.METHODS: We reviewed the cases of sixty-three patients who underwent osteochondral allograft transplantation to the distal aspect of the femur between 1972 and 1995. Five patients who resided out of the country were lost to follow-up. Indications for the allograft procedure were an age of less than fifty years and a unipolar posttraumatic osteochondral or osteochondritis dissecans defect in the distal aspect of the femur that was larger than 3 cm in diameter and 1 cm in depth.RESULTS: Fifty-eight patients ages eleven to forty-eight years at the time of surgery (mean age, twenty-eight years) were followed for a mean of 21.8 years (range, fifteen to thirty-two years). Thirteen of the fifty-eight cases requir...

Research paper thumbnail of Letter to the editor response

Journal of surgical education

We read the recently published article "Variations in the Individual Thick Lamellar Properties Wi... more We read the recently published article "Variations in the Individual Thick Lamellar Properties Within Osteons by Nanodentation" by Rho et al., which appeared in Bone 25(3), pp. 295-300, and wish to comment on several issues raised.

Research paper thumbnail of Student-led learning: a new teaching paradigm for surgical skills

The American Journal of Surgery, 2015

BACKGROUND: Competency-based education and simulation are being used more frequently in surgical ... more BACKGROUND: Competency-based education and simulation are being used more frequently in surgical skills curricula. We explored a novel student-led learning paradigm, which allows trainees to become more active participants in the learning process while maintaining expert guidance and supervision.

Research paper thumbnail of A novel multimodal platform for assessing surgical technical skills

The American Journal of Surgery, 2012

BACKGROUND: Established methods for assessing surgical performance face limitations. Global ratin... more BACKGROUND: Established methods for assessing surgical performance face limitations. Global rating scales and procedure-specific checklists are resource intensive and rely on expert opinions. Alternatives that use technology to track hand movements, such as magnetic and optical tracking systems, are generally expensive and ill suited to the surgical environment.

Research paper thumbnail of Orthopedic boot camp: Examining the effectiveness of an intensive surgical skills course

Surgery, 2011

Background. Changes in health care across the globe have had a profound impact on the number of h... more Background. Changes in health care across the globe have had a profound impact on the number of hands-on surgical training opportunities that are available to residents. In the current study, we examine whether an intensive laboratory-based skills course at the start of orthopedic surgical training is an effective mechanism for teaching core technical skills. Methods. First-year residents were divided into 3 groups (on-service, n = 8; off-service, n = 8; and a new, competency-based program that has as a major element of the curriculum a focused, intensive skills laboratory-based experience, n = 6). Baseline surgical skills were assessed prior to commencing training. The intensive skills laboratory group was then given an intensive surgical skills course, whereas the other 2 groups embarked on traditional residency. After the surgical skills course, all the residents were assessed for core surgical skills using an objective structured assessment of technical skills (OSATS) procedure. Results. Pretraining scores revealed no differences between the groups of residents using both checklist (F[2,19] = 0.852, P = .442) and global rating scores (F[2,19] = 0.704, P = .507). Post-training scores revealed a significant difference, with residents from the intensive skills laboratory group performing better on both the checklists (on-service = 78.9, off-service = 78.6, intensive skills laboratory = 92.3; F[2,19] = 6.914, P < .01) and global rating scores (on-service = 3.4, off-service = 3.4, intensive skills laboratory = 4.3; F[2,19] = 5.722, P < .01), than the other groups who showed no differences between them. Conclusion. The intensive skills course used in this study was highly effective at teaching and developing targeted surgical skills in first-year orthopedic residents. We predict that allowing residents to acquire key technical skills at the start of their training will enhance learning opportunities at later stages of training. (Surgery 2011;149:745-9.)

Research paper thumbnail of How effective is self-guided learning of clinical technical skills? It’s all about process

Medical Education, 2009

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

Research paper thumbnail of A Biomechanical Comparison Between the Thoracolumbosacral Surface Contact Area (SCA) of a Standard Backboard With Other Rigid Immobilization Surfaces

The Journal of Trauma: Injury, Infection, and Critical Care, 2009

Backboards are routinely used to protect the spine of trauma patients during transportation. Neve... more Backboards are routinely used to protect the spine of trauma patients during transportation. Nevertheless, little is known about the biomechanical properties of this type of immobilization. To evaluate the mechanical support of the thoracolumbosacral spine provided by a standard backboard in comparison with various rigid immobilization surfaces, by examining their respective surface contact area (SCA). SCAs comparisons of a standard aluminum backboard, a rigid military stretcher, an aluminum backboard covered by blanket, 3 and 5 cm thickness foam, and a cushioned stretcher were made using 12 volunteers. The evaluation was performed by a computer- mediated system that generated a diagram indicating pressure distribution and SCA score in each volunteer. These data were compared with a medical grade mattress, which served as the control group. The median backboard&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s SCA was 14.6 +/- 5.5 times smaller than the stretcher&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s SCA (range 4.6-28, average 15, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Its median SCA was essentially doubled by covering it by a standard military blanket and tripled when covered by 3 cm layer of foam. Using a 5-cm layer of foam increased the backboard&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s SCA by 11 times. Cushioning the stretcher beneath the lumbar spine and the hamstrings by folded blankets, significantly improved its median SCA (96 +/- 31.1, range 36-125, average 89.7). The backboard&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s SCA was significantly inferior to all the other surfaces. Although no dynamic evaluation was performed, these data imply that backboards need to be appropriately cushioned or alternate surfaces should be employed to improve the mechanical support during trauma patient transportation. Level of evidence, Level I.

Research paper thumbnail of Reflections on Competency-Based Education and Training for Surgical Residents

Journal of Surgical Education, 2014

Research paper thumbnail of An Inexpensive and Accurate Method for Hip Injections Without the Use of Imaging

JCR: Journal of Clinical Rheumatology, 2009

Intraarticular injections of the hip have traditionally required sonographic or fluoroscopic guid... more Intraarticular injections of the hip have traditionally required sonographic or fluoroscopic guidance assistance. Previous studies report high failure rates with injections based solely on anatomic landmarks. To examine the accuracy of a lateral injection technique in osteoarthritic patients without using image assistance. This study was conducted in the operating room in 40 consecutive patients about to undergo total hip arthroplasty. Before sedation, each patient was positioned in a lateral decubitus position. Under sterile conditions, methylene blue dye was injected through an 18G spinal needle that was inserted 1 cm proximal to the midline of the greater trochanter, and directed toward the superolateral aspect of the femoral neck, according to preoperative hip x-rays. Accuracy was assessed intraoperatively by examining the joint and surrounding tissues for the presence of dye. Injections were successful in 6 of the first 10 (60%) patients and in 25 of the remaining 30 (83.3%) patients. Overall, injections were successful in 31 of 40 (77.5%) patients with disseminated dye solely in the intracapsular space. In all 9 unsuccessful injections, the dye was located distal to the joint, along with the more lateral aspect of the femoral neck. Accuracy of injections, to the hip joint, based on anatomic landmarks and preoperative x-rays is similar to those documented for knee injections in the literature. When unsuccessful, the injected material was not found close to neurovascular structures. This technique has an acceptable learning curve and can be used safely in a standard office setting.

Research paper thumbnail of Hips with Synovial Chondromatosis May Display the Features of Femoroacetabular Impingement

The Journal of Bone and Joint Surgery (American), 2014

Both synovial chondromatosis and femoroacetabular impingement present with hip pain and may lead ... more Both synovial chondromatosis and femoroacetabular impingement present with hip pain and may lead to hip osteoarthritis. We present a small case series and describe the clinical presentation, investigation, and treatment of patients with synovial chondromatosis who also had cam-type femoroacetabular impingement involving the same hip. Five patients (four men and one woman with a mean age of thirty-four years [range, thirty to thirty-seven years]) with unilateral synovial chondromatosis of the hip presented with clinical and radiographic features of ipsilateral cam-type femoroacetabular impingement. The diagnosis of associated synovial chondromatosis was made on the basis of preoperative imaging in four of the cases. All patients were treated with surgical hip dislocation, excision of the synovial chondromatosis loose bodies, and reshaping of the femoral head-neck junction. These hips exhibited radiographic features that are not typically seen with idiopathic cam-type femoroacetabular impingement, including femoral head hypertrophy, lateralization of the femoral head, and haziness in the acetabular fossa. None of the hips showed signs of advanced osteoarthritis intraoperatively. The alpha angle improved from a mean of 72.4° preoperatively to 42.6° postoperatively. At a mean of twenty-two months of follow-up, the patients had a mean Harris hip score of 80.6, substantially improved from the preoperative value of 39. Hips with synovial chondromatosis may present with clinical and radiographic features resembling those of cam-type femoroacetabular impingement. As simultaneous treatment of both conditions is best accomplished with surgical hip dislocation rather than other, less-extensive surgical approaches, we recommend preoperative consideration of synovial chondromatosis in patients presenting with unilateral cam-type femoroacetabular impingement.

Research paper thumbnail of Total Knee Arthroplasty After Failed Distal Femoral Varus Osteotomy Using Selectively Stemmed Posterior Stabilized Components

The Journal of Arthroplasty, 2011

The purpose of this study was to evaluate the outcomes of patients treated with total knee arthro... more The purpose of this study was to evaluate the outcomes of patients treated with total knee arthroplasty (TKA) for progression of arthritis after distal femoral varus osteotomy. Twentytwo consecutive distal femoral varus osteotomies converted to TKA were reviewed at a mean follow-up of 5 years (range, 2-14 years). Stemmed femoral or tibial components were used in 5 knees with poor bone quality, while the remaining 17 knees were treated with unstemmed components. The mean Knee Society knee and function scores in surviving knees were 91 points (range, 67-100 points) and 64 points (range, 50-70 points) respectively at final follow-up. Two patients underwent revision arthroplasty for polyethylene wear and component loosening at 8 and 11 years after the index arthroplasty, respectively. Standard components provide satisfactory stability in TKA after distal femoral varus osteotomy after appropriate ligamentous balancing, without the need for stemmed or highly constrained components in the majority of patients. Keywords: distal femoral varus osteotomy, total knee arthroplasty, fresh chondral allograft, stemmed components.

Research paper thumbnail of Revision Total Knee Arthroplasty for Component Malrotation is Highly Beneficial

The Journal of Arthroplasty, 2010

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

Research paper thumbnail of Dislocation and Infection After Revision Total Hip Arthroplasty

The Journal of Arthroplasty, 2011

Dislocation and infection are common complications of total hip arthroplasty (THA). This study ev... more Dislocation and infection are common complications of total hip arthroplasty (THA). This study evaluated the correlation between the number of revision THAs and the incidence of these complications. Data were obtained from 749 revision THAs. Average follow-up was 13.2 ± 5.9 years. Patients were grouped as first, second, third, and fourth or greater revision THA. Dislocation rates (5.68%, 7.69%, 8.33%, and 27.45%) and infection rates (1.35%, 1.92%, 2.5%, and 7.84%) in the first, second, third, and fourth or greater groups, respectively, correlated directly with the revision number and were highest (P b .001) in the fourth or greater group. Dislocation and infection are exponentially correlated with the number of revision THA. From the fourth revision onward, those risks are multiplied.

Research paper thumbnail of Periprosthetic Fractures of the Knee

The Journal of Arthroplasty, 2007

Periprosthetic total knee arthroplasty fractures of the distal femur and proximal tibia can be am... more Periprosthetic total knee arthroplasty fractures of the distal femur and proximal tibia can be among the most difficult complications to effectively manage within the realm of joint replacement. These fractures can occur intraoperatively or postoperatively. Intraoperative fractures can be avoided by early removal of hardware, use of stems for stress risers, and use of intraoperative radiographs whenever further visualization is required. Intraoperative fractures should be fixed and then protected by a stem and avoidance of weight bearing until healed. Postoperative fractures can occur with significant trauma, or minor injury when osteolysis is present. Operative management is almost always required. The method of treatment depends upon factors such as the stability of implant fixation, location of the fracture, quality of the bone, and presence or absence of an open-box femoral component. Key words: total knee arthroplasty, periprosthetic fracture, revision knee arthroplasty.

Research paper thumbnail of Modified Trochanteric Slide for Complex Hip Arthroplasty

The Journal of Arthroplasty, 2010

The sliding trochanteric osteotomy preserves vastus lateralis continuity with the osteotomized gr... more The sliding trochanteric osteotomy preserves vastus lateralis continuity with the osteotomized greater trochanter (GT) and the abductors. The modified trochanteric sliding osteotomy (MTSO) also preserves the posterior capsule and external rotators to reduce the risk of dislocations. The purpose of this study was to evaluate our clinical and radiographic results of the MTSO exposure. Eighty-three MTSOs were reviewed. Follow-up range was 12 to 126 months. Seventy osteotomies (84.4%) healed with bony union, 9 (10.8%) had fibrous union, and 4 (4.8%) had nonunion. There was no correlation between the width of the osteotomy, intraoperative fragmentation of the GT, or the type of femoral component and the rate of union. Six (7.2%) patients developed a new abductor lurch. Patients with union of the GT had 2.8% of a lurch, and patients with either fibrous union or nonunion had a 30.7% of a lurch (P b .05). There were 4 (4.8%) postoperative dislocations. The benefits of MTSO have been well described, and this study provides evidence of an acceptably low complication rate. Keywords: revision total hip arthroplasty, surgical approach, trochanteric slide osteotomy, acetabular component.

Research paper thumbnail of Treatment of Failed Allograft Prosthesis Composites Used for Hip Arthroplasty in the Setting of Severe Proximal Femoral Bone Defects

The Journal of Arthroplasty, 2014

This study assessed failures of allograft prosthesis composites (APC) and revisions with a new AP... more This study assessed failures of allograft prosthesis composites (APC) and revisions with a new APC. Twenty-one patients with failed APC&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s after revision hip arthroplasty with severe proximal femoral bone loss underwent revision with a new APC. Causes of failure were aseptic loosening (18 patients), infection (3 patients). Of these 21 APC revisions, two patients failed (after 60, 156 months). The 5 and 10 year survival rates were 83.5% (95% CI, 79-100%, number at risk 12 and 6 accordingly). In addition, two patients had non-union at the host-allograft bone junction and were augmented with bone autograft and plate. These results suggest that failed APCs may be revised to a new APC with a predictable outcome.

Research paper thumbnail of Risk factors for subsidence of a modular tapered femoral stem used for revision total hip arthroplasty

The Journal of Arthroplasty, 2015

The purpose of this study was to determine the incidence, and the clinical and radiographic risk ... more The purpose of this study was to determine the incidence, and the clinical and radiographic risk factors for significant subsidence of a cementless, modular tapered revision femoral stem. Femoral stem subsidence of at least 10 mm or subsidence requiring revision was considered significant subsidence. Ninety-seven patients (99 hips) were included with minimum radiographic follow-up of one year (mean 34 months; range, 12-91 months). The mean stem subsidence was 4.5 mm (range, 0-44 mm). Fourteen out of 99 (14.1%) stems had significant subsidence and 6 (6.1%) stems required revision due to subsidence. Patient weight greater than 80 kg (P=0.04) and femoral stem press-fit distance of less than 2 cm (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01) were both independent risk factors for significant stem subsidence.

Research paper thumbnail of The Outcome of Modified Extended Trochanteric Osteotomy in Revision THA for Vancouver B2/B3 Periprosthetic Fractures of the Femur

The Journal of Arthroplasty, 2014

We hypothesised that a modified ETO in patients undergoing revision total hip arthroplasty (THA) ... more We hypothesised that a modified ETO in patients undergoing revision total hip arthroplasty (THA) for treatment of Vancouver B2/B3 peri-prosthetic fractures would be associated with good clinical outcomes. A retrospective review was conducted of 34 patients (mean age 73 years). At mean follow-up of 57 months, the ETO had healed in all patients. Two patients had subsidence of the femoral stem at two and three years postoperatively requiring revision, and one patient had a dislocation 3 months after surgery. The mean Harris Hip Score at the time of the final follow-up was 76.9 (range, 46-95); 23/34 patients had an excellent result, 7/34 a good result, and 4/34 a poor result. We conclude that satisfactory outcomes can be obtained using this technique.

Research paper thumbnail of Long-Term Follow-Up of Distal Femoral Varus Osteotomy of the Knee

Journal of Arthroplasty, 2007

Distal femoral varus osteotomy (DFVO) of the knee may be indicated for young, active patients wit... more Distal femoral varus osteotomy (DFVO) of the knee may be indicated for young, active patients with unicompartmental arthritis and valgus deformity. We report on 40 DFVOs with a mean follow-up of 123 months. At the most recent follow-up, 24 knees had good or excellent results (60%), 3 had fair results (7.5%), and 3 had poor results (7.5%). Four in the

Research paper thumbnail of Management of bone loss: structural grafts in revision total knee arthroplasty

Clinical orthopaedics and related research, 2006

Massive bone defects are challenging problems in revision knee surgery. When defects are large an... more Massive bone defects are challenging problems in revision knee surgery. When defects are large and uncontained (without a cortical rim), structural allografts may be used to provide support for femoral and tibial components. This study reviewed 68 structural allografts at a mean of 5.4 years for clinical and radiographic outcomes. Indications for grafts included periprosthetic fracture in 19 knees, aseptic loosening in 29, infection in 11 and instability in 2. Seven knees had both femoral and tibial allografts. Multiple implant designs were used including 7 hinged prostheses. Thirteen knees (13/61) failed due to graft related complications including one graft nonunion, three aseptic loosenings, three periprosthetic fractures, four infections, and two for instability. The case of graft nonunion was successfully treated with revision fixation and autologous bone graft. There were three cases of graft resorption, two graded as severe and one as moderate. These results are satisfactory ...

Research paper thumbnail of Distal Femoral Fresh Osteochondral Allografts: Follow-up at a Mean of Twenty-two Years

The Journal of bone and joint surgery. American volume, Jan 2, 2014

Osteochondral defects of the knee in young, active patients represent a challenge to the orthopae... more Osteochondral defects of the knee in young, active patients represent a challenge to the orthopaedic surgeon. Our study examined long-term outcomes of the use of fresh allograft for posttraumatic osteochondral and osteochondritis dissecans defects in the distal aspect of the femur.METHODS: We reviewed the cases of sixty-three patients who underwent osteochondral allograft transplantation to the distal aspect of the femur between 1972 and 1995. Five patients who resided out of the country were lost to follow-up. Indications for the allograft procedure were an age of less than fifty years and a unipolar posttraumatic osteochondral or osteochondritis dissecans defect in the distal aspect of the femur that was larger than 3 cm in diameter and 1 cm in depth.RESULTS: Fifty-eight patients ages eleven to forty-eight years at the time of surgery (mean age, twenty-eight years) were followed for a mean of 21.8 years (range, fifteen to thirty-two years). Thirteen of the fifty-eight cases requir...

Research paper thumbnail of Letter to the editor response

Journal of surgical education

We read the recently published article "Variations in the Individual Thick Lamellar Properties Wi... more We read the recently published article "Variations in the Individual Thick Lamellar Properties Within Osteons by Nanodentation" by Rho et al., which appeared in Bone 25(3), pp. 295-300, and wish to comment on several issues raised.

Research paper thumbnail of Student-led learning: a new teaching paradigm for surgical skills

The American Journal of Surgery, 2015

BACKGROUND: Competency-based education and simulation are being used more frequently in surgical ... more BACKGROUND: Competency-based education and simulation are being used more frequently in surgical skills curricula. We explored a novel student-led learning paradigm, which allows trainees to become more active participants in the learning process while maintaining expert guidance and supervision.

Research paper thumbnail of A novel multimodal platform for assessing surgical technical skills

The American Journal of Surgery, 2012

BACKGROUND: Established methods for assessing surgical performance face limitations. Global ratin... more BACKGROUND: Established methods for assessing surgical performance face limitations. Global rating scales and procedure-specific checklists are resource intensive and rely on expert opinions. Alternatives that use technology to track hand movements, such as magnetic and optical tracking systems, are generally expensive and ill suited to the surgical environment.

Research paper thumbnail of Orthopedic boot camp: Examining the effectiveness of an intensive surgical skills course

Surgery, 2011

Background. Changes in health care across the globe have had a profound impact on the number of h... more Background. Changes in health care across the globe have had a profound impact on the number of hands-on surgical training opportunities that are available to residents. In the current study, we examine whether an intensive laboratory-based skills course at the start of orthopedic surgical training is an effective mechanism for teaching core technical skills. Methods. First-year residents were divided into 3 groups (on-service, n = 8; off-service, n = 8; and a new, competency-based program that has as a major element of the curriculum a focused, intensive skills laboratory-based experience, n = 6). Baseline surgical skills were assessed prior to commencing training. The intensive skills laboratory group was then given an intensive surgical skills course, whereas the other 2 groups embarked on traditional residency. After the surgical skills course, all the residents were assessed for core surgical skills using an objective structured assessment of technical skills (OSATS) procedure. Results. Pretraining scores revealed no differences between the groups of residents using both checklist (F[2,19] = 0.852, P = .442) and global rating scores (F[2,19] = 0.704, P = .507). Post-training scores revealed a significant difference, with residents from the intensive skills laboratory group performing better on both the checklists (on-service = 78.9, off-service = 78.6, intensive skills laboratory = 92.3; F[2,19] = 6.914, P < .01) and global rating scores (on-service = 3.4, off-service = 3.4, intensive skills laboratory = 4.3; F[2,19] = 5.722, P < .01), than the other groups who showed no differences between them. Conclusion. The intensive skills course used in this study was highly effective at teaching and developing targeted surgical skills in first-year orthopedic residents. We predict that allowing residents to acquire key technical skills at the start of their training will enhance learning opportunities at later stages of training. (Surgery 2011;149:745-9.)

Research paper thumbnail of How effective is self-guided learning of clinical technical skills? It’s all about process

Medical Education, 2009

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

Research paper thumbnail of A Biomechanical Comparison Between the Thoracolumbosacral Surface Contact Area (SCA) of a Standard Backboard With Other Rigid Immobilization Surfaces

The Journal of Trauma: Injury, Infection, and Critical Care, 2009

Backboards are routinely used to protect the spine of trauma patients during transportation. Neve... more Backboards are routinely used to protect the spine of trauma patients during transportation. Nevertheless, little is known about the biomechanical properties of this type of immobilization. To evaluate the mechanical support of the thoracolumbosacral spine provided by a standard backboard in comparison with various rigid immobilization surfaces, by examining their respective surface contact area (SCA). SCAs comparisons of a standard aluminum backboard, a rigid military stretcher, an aluminum backboard covered by blanket, 3 and 5 cm thickness foam, and a cushioned stretcher were made using 12 volunteers. The evaluation was performed by a computer- mediated system that generated a diagram indicating pressure distribution and SCA score in each volunteer. These data were compared with a medical grade mattress, which served as the control group. The median backboard&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s SCA was 14.6 +/- 5.5 times smaller than the stretcher&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s SCA (range 4.6-28, average 15, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Its median SCA was essentially doubled by covering it by a standard military blanket and tripled when covered by 3 cm layer of foam. Using a 5-cm layer of foam increased the backboard&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s SCA by 11 times. Cushioning the stretcher beneath the lumbar spine and the hamstrings by folded blankets, significantly improved its median SCA (96 +/- 31.1, range 36-125, average 89.7). The backboard&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s SCA was significantly inferior to all the other surfaces. Although no dynamic evaluation was performed, these data imply that backboards need to be appropriately cushioned or alternate surfaces should be employed to improve the mechanical support during trauma patient transportation. Level of evidence, Level I.

Research paper thumbnail of Reflections on Competency-Based Education and Training for Surgical Residents

Journal of Surgical Education, 2014

Research paper thumbnail of An Inexpensive and Accurate Method for Hip Injections Without the Use of Imaging

JCR: Journal of Clinical Rheumatology, 2009

Intraarticular injections of the hip have traditionally required sonographic or fluoroscopic guid... more Intraarticular injections of the hip have traditionally required sonographic or fluoroscopic guidance assistance. Previous studies report high failure rates with injections based solely on anatomic landmarks. To examine the accuracy of a lateral injection technique in osteoarthritic patients without using image assistance. This study was conducted in the operating room in 40 consecutive patients about to undergo total hip arthroplasty. Before sedation, each patient was positioned in a lateral decubitus position. Under sterile conditions, methylene blue dye was injected through an 18G spinal needle that was inserted 1 cm proximal to the midline of the greater trochanter, and directed toward the superolateral aspect of the femoral neck, according to preoperative hip x-rays. Accuracy was assessed intraoperatively by examining the joint and surrounding tissues for the presence of dye. Injections were successful in 6 of the first 10 (60%) patients and in 25 of the remaining 30 (83.3%) patients. Overall, injections were successful in 31 of 40 (77.5%) patients with disseminated dye solely in the intracapsular space. In all 9 unsuccessful injections, the dye was located distal to the joint, along with the more lateral aspect of the femoral neck. Accuracy of injections, to the hip joint, based on anatomic landmarks and preoperative x-rays is similar to those documented for knee injections in the literature. When unsuccessful, the injected material was not found close to neurovascular structures. This technique has an acceptable learning curve and can be used safely in a standard office setting.

Research paper thumbnail of Hips with Synovial Chondromatosis May Display the Features of Femoroacetabular Impingement

The Journal of Bone and Joint Surgery (American), 2014

Both synovial chondromatosis and femoroacetabular impingement present with hip pain and may lead ... more Both synovial chondromatosis and femoroacetabular impingement present with hip pain and may lead to hip osteoarthritis. We present a small case series and describe the clinical presentation, investigation, and treatment of patients with synovial chondromatosis who also had cam-type femoroacetabular impingement involving the same hip. Five patients (four men and one woman with a mean age of thirty-four years [range, thirty to thirty-seven years]) with unilateral synovial chondromatosis of the hip presented with clinical and radiographic features of ipsilateral cam-type femoroacetabular impingement. The diagnosis of associated synovial chondromatosis was made on the basis of preoperative imaging in four of the cases. All patients were treated with surgical hip dislocation, excision of the synovial chondromatosis loose bodies, and reshaping of the femoral head-neck junction. These hips exhibited radiographic features that are not typically seen with idiopathic cam-type femoroacetabular impingement, including femoral head hypertrophy, lateralization of the femoral head, and haziness in the acetabular fossa. None of the hips showed signs of advanced osteoarthritis intraoperatively. The alpha angle improved from a mean of 72.4° preoperatively to 42.6° postoperatively. At a mean of twenty-two months of follow-up, the patients had a mean Harris hip score of 80.6, substantially improved from the preoperative value of 39. Hips with synovial chondromatosis may present with clinical and radiographic features resembling those of cam-type femoroacetabular impingement. As simultaneous treatment of both conditions is best accomplished with surgical hip dislocation rather than other, less-extensive surgical approaches, we recommend preoperative consideration of synovial chondromatosis in patients presenting with unilateral cam-type femoroacetabular impingement.

Research paper thumbnail of Total Knee Arthroplasty After Failed Distal Femoral Varus Osteotomy Using Selectively Stemmed Posterior Stabilized Components

The Journal of Arthroplasty, 2011

The purpose of this study was to evaluate the outcomes of patients treated with total knee arthro... more The purpose of this study was to evaluate the outcomes of patients treated with total knee arthroplasty (TKA) for progression of arthritis after distal femoral varus osteotomy. Twentytwo consecutive distal femoral varus osteotomies converted to TKA were reviewed at a mean follow-up of 5 years (range, 2-14 years). Stemmed femoral or tibial components were used in 5 knees with poor bone quality, while the remaining 17 knees were treated with unstemmed components. The mean Knee Society knee and function scores in surviving knees were 91 points (range, 67-100 points) and 64 points (range, 50-70 points) respectively at final follow-up. Two patients underwent revision arthroplasty for polyethylene wear and component loosening at 8 and 11 years after the index arthroplasty, respectively. Standard components provide satisfactory stability in TKA after distal femoral varus osteotomy after appropriate ligamentous balancing, without the need for stemmed or highly constrained components in the majority of patients. Keywords: distal femoral varus osteotomy, total knee arthroplasty, fresh chondral allograft, stemmed components.

Research paper thumbnail of Revision Total Knee Arthroplasty for Component Malrotation is Highly Beneficial

The Journal of Arthroplasty, 2010

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

Research paper thumbnail of Dislocation and Infection After Revision Total Hip Arthroplasty

The Journal of Arthroplasty, 2011

Dislocation and infection are common complications of total hip arthroplasty (THA). This study ev... more Dislocation and infection are common complications of total hip arthroplasty (THA). This study evaluated the correlation between the number of revision THAs and the incidence of these complications. Data were obtained from 749 revision THAs. Average follow-up was 13.2 ± 5.9 years. Patients were grouped as first, second, third, and fourth or greater revision THA. Dislocation rates (5.68%, 7.69%, 8.33%, and 27.45%) and infection rates (1.35%, 1.92%, 2.5%, and 7.84%) in the first, second, third, and fourth or greater groups, respectively, correlated directly with the revision number and were highest (P b .001) in the fourth or greater group. Dislocation and infection are exponentially correlated with the number of revision THA. From the fourth revision onward, those risks are multiplied.

Research paper thumbnail of Periprosthetic Fractures of the Knee

The Journal of Arthroplasty, 2007

Periprosthetic total knee arthroplasty fractures of the distal femur and proximal tibia can be am... more Periprosthetic total knee arthroplasty fractures of the distal femur and proximal tibia can be among the most difficult complications to effectively manage within the realm of joint replacement. These fractures can occur intraoperatively or postoperatively. Intraoperative fractures can be avoided by early removal of hardware, use of stems for stress risers, and use of intraoperative radiographs whenever further visualization is required. Intraoperative fractures should be fixed and then protected by a stem and avoidance of weight bearing until healed. Postoperative fractures can occur with significant trauma, or minor injury when osteolysis is present. Operative management is almost always required. The method of treatment depends upon factors such as the stability of implant fixation, location of the fracture, quality of the bone, and presence or absence of an open-box femoral component. Key words: total knee arthroplasty, periprosthetic fracture, revision knee arthroplasty.

Research paper thumbnail of Modified Trochanteric Slide for Complex Hip Arthroplasty

The Journal of Arthroplasty, 2010

The sliding trochanteric osteotomy preserves vastus lateralis continuity with the osteotomized gr... more The sliding trochanteric osteotomy preserves vastus lateralis continuity with the osteotomized greater trochanter (GT) and the abductors. The modified trochanteric sliding osteotomy (MTSO) also preserves the posterior capsule and external rotators to reduce the risk of dislocations. The purpose of this study was to evaluate our clinical and radiographic results of the MTSO exposure. Eighty-three MTSOs were reviewed. Follow-up range was 12 to 126 months. Seventy osteotomies (84.4%) healed with bony union, 9 (10.8%) had fibrous union, and 4 (4.8%) had nonunion. There was no correlation between the width of the osteotomy, intraoperative fragmentation of the GT, or the type of femoral component and the rate of union. Six (7.2%) patients developed a new abductor lurch. Patients with union of the GT had 2.8% of a lurch, and patients with either fibrous union or nonunion had a 30.7% of a lurch (P b .05). There were 4 (4.8%) postoperative dislocations. The benefits of MTSO have been well described, and this study provides evidence of an acceptably low complication rate. Keywords: revision total hip arthroplasty, surgical approach, trochanteric slide osteotomy, acetabular component.

Research paper thumbnail of Treatment of Failed Allograft Prosthesis Composites Used for Hip Arthroplasty in the Setting of Severe Proximal Femoral Bone Defects

The Journal of Arthroplasty, 2014

This study assessed failures of allograft prosthesis composites (APC) and revisions with a new AP... more This study assessed failures of allograft prosthesis composites (APC) and revisions with a new APC. Twenty-one patients with failed APC&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s after revision hip arthroplasty with severe proximal femoral bone loss underwent revision with a new APC. Causes of failure were aseptic loosening (18 patients), infection (3 patients). Of these 21 APC revisions, two patients failed (after 60, 156 months). The 5 and 10 year survival rates were 83.5% (95% CI, 79-100%, number at risk 12 and 6 accordingly). In addition, two patients had non-union at the host-allograft bone junction and were augmented with bone autograft and plate. These results suggest that failed APCs may be revised to a new APC with a predictable outcome.