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Background The world of medicine is constantly changing, and with it the continuing professional development (CPD) needs of physicians. As the CPD landscape is shifting away from unidirectional delivery of knowledge through live large group learning (conferences) and is placing increased emphasis on new approaches for skills training not taught a decade ago, a new approach is needed. Approach Using design thinking techniques, we hosted a full-day retreat for emergency medicine stakeholders in Hamilton and the surrounding region. Prior to the retreat we collected medico-legal data on emergency physicians in our region and performed a needs assessment survey. At the retreat, we had participants brainstorm ideas for CPD, generate archetypes for end-users, then generate solutions to the problems they had identified. These proposals were presented to the larger group for feedback and refinement. Evaluation The Design Thinking Retreat generated five main pillars for action by our CPD team. 1) Simulation/procedural learning (staff simulation, procedural skills day, in situ simulation); 2) Asynchronous learning (website and podcast); 3) Synchronous learning (small group sessions for staff); 4) Community connectivity (online platform for collaboration and communication); and 5) Coaching & mentorship (focused coaching for specific practice improvement, improved onboarding for new staff). Reflection These ideas have vastly increased engagement in CPD. Stakeholder consultation via design thinking may be a key approach for educators to use.

Background: There has been growing interest in using theory-driven research to develop and evaluate continuing medical education (CME) activities. Within health professions education, testing has been shown to promote learning in a variety of different contexts, an effect referred to as test-enhanced learning (TEL). However, the extent to which TEL generalizes to CME remains unclear. The purpose of this study was to investigate whether physicians who received two intervening tests following a CME event would experience a TEL effect relative to physicians who received additional study material to review without testing. Methods: Forty-nine physicians were recruited during a local CME activity. Physicians were randomized to either a) the test group (n=26), where participants completed two 20 multiple-choice question (MCQ) quizzes related to the lecture content or b) the study group (n=23), where participants studied the same information without testing. Testing and studying occurred independently during the CME activity, and then four weeks later online. At eight weeks, participants completed a final 20-item MCQ online test. A between-subjects t-test was used to compare performance on the final test as a function of the initial educational activity (test group vs. study group).Results: Performance on the final MCQ test was equivalent for both test (Mean (SD): 75% (9.9)) and study-only (77% (7.3)) conditions (t(47) = 0.94, p=0.35). Conclusion: The null findings in the present study are contrary to previous findings demonstrating TEL among novice learner populations. The lack of TEL highlights several programmatic considerations that should be factored in before implementing TEL as a part of CME.

Context: The CanMEDS framework promotes the development of competencies required to be an effective physician. However, it is still not well understood how to apply such frameworks to CPD contexts, particularly with respect to intrinsic competencies. Objective: This study explores whether physician narratives around challenging cases would provide information regarding learning needs that could help guide the development of CPD activities for intrinsic CanMEDS competencies. Methods: We surveyed medical and surgical specialists from Southern Ontario using an online survey. To assess perceived needs, participants were asked, ‘Describe three CPD topic you would like to learn about in the next 12 months’. To identify learning needs that may have arisen from problems encountered in practice, participants were asked, ‘Describe three challenging situations encountered in the past 12 months.’ Responses to the two open-ended questions were analyzed using thematic content analysis. Results: Responses were received from 411 physicians, resulting in 226 intrinsic CanMEDS codes for perceived learning needs and 210 intrinsic codes for challenges encountered in practices. Discrepancies in the frequency of intrinsic roles were observed between the two questions. Specifically, Leader (28%), Scholar (43%), and Professional (16%) roles were frequently described perceived learning needs, as opposed to challenges in practice (Leader: 3%; Scholar: 2%; and Professional: 8%. Conversely, Communicator 39%, Health Advocate 39%, and to a lesser extent Collaborator 11%) roles were frequently described in narratives surrounding challenges in practice, but appeared in

Background Point-of-Care Ultrasound (PoCUS) is an ultrasound examination performed by the clinician to answer a focused question or guide an invasive procedure. Despite gaining popularity and evidence supporting the use of PoCUS, core Internal Medicine (IM) residency programs in Canada have yet to implement a comprehensive PoCUS curriculum. The objective of this study was to create a formal PoCUS curriculum. Methods We conducted a systematic needs assessment with a survey that assessed IM attending and resident comfort, training, and application of PoCUS. We also performed a literature review of selected PoCUS-guided procedures and diagnostics to assess the evidence. A working group analyzed the collected data and designed a graduated 3-year curriculum. Results The needs assessment demonstrated that PoCUS education was both necessary and in high demand. The PoCUS-guided procedures and diagnostics that were identified by the survey to be necessary for IM training were then evaluated by a literature review. Based on the evidence, a progressive 3-year curriculum was created. The working group decided on the method and timing of curriculum delivery. Conclusion McMaster University is the first IM residency program to introduce a graduated 3-year curriculum complete with competency assessment and quality assurance. Résumé Contexte L'échographie ponctuelle est un examen d'échographie effectué par le clinicien pour répondre à une question ciblée ou guider une procédure invasive. Malgré l'obtention de la popularité et des preuves appuyant l'utilisation de la messagerie instantanée, les programmes de résidence au Canada pour la médecine interne de base (GI) n'ont pas encore mis en œuvre un programme exhaustif. L'objectif de cette étude était de créer un programme d'études officiel. Méthodes Nous avons effectué une évaluation systématique des besoins avec un sondage qui évaluait la présence de GI et le confort des résidents, la formation et l'application de ces programmes. Nous avons également effectué un examen de la documentation de certaines procédures et diagnostics guidés pour évaluer la preuve. Un groupe de travail a analysé les données collectées et conçu un programme gradué de trois ans. Résultats L'évaluation des besoins a démontré que l'éducation était à la fois nécessaire et trèsdemandée. Les procédures et les diagnostics qui ont été identifiés par le sondage comme étant nécessaires à la formation en GI ont ensuite été évalués par un examen de la documentation. Sur la base des données probantes, un programme d'études progressive de trois ans a été créé. Le groupe de travail a décidé de la méthode et ducalendrier de l'exécution des programmes. Conclusion L'Université McMaster est le premier programme de résidence en GI à présenter un programme gradué de trois ans complété par l'évaluation des compétences et l'assurance de la qualité.

Summary Background Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths, which anticoagulation therapy could prevent. Dabigatran prevents perioperative venous thromboembolism, but whether this drug can prevent a broader range of vascular complications in patients with MINS is unknown. The MANAGE trial assessed the potential of dabigatran to prevent major vascular complications among such patients. Methods In this international, randomised, placebo-controlled trial, we recruited patients from 84 hospitals in 19 countries. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS. Patients were randomly assigned (1:1) to receive dabigatran 110 mg orally twice daily or matched placebo for a maximum of 2 years or until termination of the trial and, using a partial 2-by-2 factorial design, patients not taking a proton-pump inhibitor were also randomly assigned (1:1) to omeprazole 20 mg once daily, for which results will be reported elsewhere, or matched placebo to measure its effect on major upper gastrointestinal complications. Research personnel randomised patients through a central 24 h computerised randomisation system using block randomisation, stratified by centre. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary efficacy outcome was the occurrence of a major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism. The primary safety outcome was a composite of life-threatening, major, and critical organ bleeding. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01661101. Findings Between Jan 10, 2013, and July 17, 2017, we randomly assigned 1754 patients to receive dabigatran (n=877) or placebo (n=877); 556 patients were also randomised in the omeprazole partial factorial component. Study drug was permanently discontinued in 401 (46%) of 877 patients allocated to dabigatran and 380 (43%) of 877 patients allocated to placebo. The composite primary efficacy outcome occurred in fewer patients randomised to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs 133 [15%] of 877 patients assigned to placebo; hazard ratio [HR] 0·72, 95% CI 0·55–0·93; p=0·0115). The primary safety composite outcome occurred in 29 patients (3%) randomised to dabigatran and 31 patients (4%) randomised to placebo (HR 0·92, 95% CI 0·55–1·53; p=0·76). Interpretation Among patients who had MINS, dabigatran 110 mg twice daily lowered the risk of major vascular complications, with no significant increase in major bleeding. Patients with MINS have a poor prognosis; dabigatran 110 mg twice daily has the potential to help many of the 8 million adults globally who have MINS to reduce their risk of a major vascular complication. Funding Boehringer Ingelheim and Canadian Institutes of Health Research.

Background: Point of Care Ultrasound (PoCUS) is an ultrasound examination performed by the clinician to answer a question or guide a procedure. Few Internal Medicine (IM) programs teach a formal PoCUS curriculum. The objective of this study is to conduct a systematic needs assessment for the introduction of a PoCUS curriculum to an IM program.Methods: A survey was distributed to all IM staff and residents. Participants rated their comfort, training, and use of PoCUS. Descriptive statistics were calculated using SPSS software.Results: Participants self-identified as “neutral” on comfort for using PoCUS for diagnostic applications and many lacked formal diagnostic training (9.7% in residents vs 32% in staff, χ2=10.5, P=0.002). Despite this inexperience, 26.9% of residents use PoCUS for diagnostic applications.Conclusion: A third of residents are using PoCUS despite a lack in formal training, suggesting that PoCUS should be introduced to the IM curriculum

Medical simulation is the use of a device or series of devices to emulate anatomy, real-life clinical situations, and clinical procedures for the purposes of education, evaluation, and research.1,2 Simulation is a powerful tool in the education and evaluation of physicians and is rapidly becoming a central thread in the fabric of medical education.3 The effectiveness of simulation-based medical education (SBME) can be optimized by integrating simulation into an overall curriculum.4 Internal medicine training programs are introducing procedural training using simulation but are not as advanced as other programs, such as anesthesia and emergency medicine, in the use of technology-based simulation utilizing high-fidelity fullsize mannequins.5 We feel simulation can be used to teach a wide range of CanMEDS competencies, and a comprehensive simulation curriculum should become a standard in internal medicine residency training.

Revision arthroplasty is often required for confirmed cases of symptomatic tibiofemoral instability after total knee arthroplasty (TKA). We evaluated the results of revision for TKA instability in a consecutive series of 67 patients (68 knees) between 2000 and 2006. Outcome measures were surgeon-based assessment of knee stability, Knee Society Score, and Short Form Health Survey 36. At an average of 39 months of follow-up, the mean Knee Society Score and Short Form Health Survey 36 physical and mental scores were 76, 53, and 67 points, respectively. Knee instability persisted in 14 patients (22%). Data at the 95% confidence level revealed that revising both the femoral and tibial components, the use of femoral augments, and smaller joint line elevation as measured on radiographs correlated significantly with achieving a stable knee. In revision surgery for TKA instability, revision of both components and the use of femoral augments seem to offer the most predictable outcome.

Background: Traditionally, the results of revision total knee arthroplasty have been determined with use of surgeon-based measures such as the Knee Society rating system. Recently, outcome and quality-of-life measures have shifted toward a greater emphasis on patient-based evaluation. The aim of our study was to determine the validity and respon- siveness of the Knee Society rating system compared with the Short Form-36 health survey (SF-36), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and a four-question 4-point Likert scale satisfaction questionnaire following revision total knee arthroplasty. Methods: A total of 152 patients underwent revision total knee arthroplasty at our institution, between August 2003 and January 2007, and had a two-year follow-up evaluation after revision surgery. The SF-36, WOMAC, Knee Society rating system, and satisfaction scores were completed preoperatively and postoperatively. Spearman correlation coefficients were calculated to determine the degree of correlation for each outcome scale. The SF-36, WOMAC, and patient satis- faction were correlated with the Knee Society rating system. Results: Both before and after surgery, the correlation among items of the Knee Society rating system displayed low to negligible levels of association. The Knee Society rating system pain score showed modest levels of convergent construct validity with the WOMAC and SF-36. However, the Knee Society functional score displayed negligible to low correlation with its WOMAC functional counterpart preoperatively. The Knee Society pain and functional scores, respectively, showed marked and moderate association with satisfaction. The change in the Knee Society pain and functional scores had moderate association with the SF-36 and WOMAC counterparts, except low correlation was displayed between the pain scores for the Knee Society rating system and the SF-36. The Knee Society rating system pain score was found to be the most responsive of the measures with a standardized response mean of 1.6, whereas the Knee Society rating system functional score was found to be the least responsive at 0.7. Conclusions: Currently, there is no so-called gold standard that optimally reflects the status of the knee, as well as the patient, prior to and following revision total knee arthroplasty. Ideally, numerous assessment scales should be administered to the patient in order to accurately reflect the patient characteristics for the purpose of academic study, but from a practical standpoint, this may not be feasible. We encourage further research and development of a simple and concise standardized questionnaire for use before and after revision total knee arthroplasty.

The orthopedic community has begun to witness a worrisome rise in the incidence of periprosthetic joint infections (PJIs) caused by resistant organisms. Besides other challenges associated with treating these infections, it appears that these infections may pose a higher cost compared to infections caused by sensitive organisms. Significantly higher cost of care for treatment of infections due to methicillin-resistant organisms were seen at a mean of $107 264 per case compared to $68 053 for treating PJI caused by sensitive strains (P

Recurrent or persistent infection after two-stage exchange arthroplasty for previously infected total knee replacement is a challenging clinical situation. We asked whether a second two-stage procedure could eradicate the infection and preserve knee function. We evaluated 18 selected patients with failed two-stage total knee arthroplasty implantation treated with a second two-stage reimplantation between 1999 and 2005. Failure of treatment was defined as recurrence or persistence of infection. The minimum followup was 24 months (mean, 40 months; range, 24–83 months). Recurrent or persistent infection was diagnosed in four of 18 patients, two of whom were successfully treated with a third two-stage exchange arthroplasty. Knee Society score questionnaires administered at the last followup showed an average Knee Society knee score of 73 points (range, 24–100 points) and an average functional score of 49 points (range, 20–90 points). The data suggest repeat two-stage exchange arthroplasty is a reasonable option for eradicating periprosthetic infection, relieving pain, and achieving a satisfactory level of function for some patients. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Prosthetic joint infections (PJI) caused by methicillin-resistant staphylococci represent a major therapeutic challenge. We examined the effectiveness of surgical treatment in treating infection of total hip or knee arthroplasty caused by methicillin-resistant staphylococcal strains and the variables influencing treatment success. One hundred and twenty-seven patients were treated at our institution between 1999 and 2006. There were 58 men and 69 women, with an average age of 66 years. Patients were followed for a minimum of 2 years or until recurrence of infection. Débridement and retention of the prosthesis was performed in 35 patients and resection arthroplasty in 92. Débridement controlled the infection in only 37% of cases whereas two-stage exchange arthroplasty controlled the infection in 75% of hips and 60% of knees. Preexisting cardiac disease was associated with a higher likelihood of failure to control infection in all treatment groups. Antibiotic-resistant Staphylococci continue to compromise treatment outcome of prosthetic joint infections, especially in patients with medical comorbidities. New preventive and therapeutic strategies are needed.Level IV, therapeutic study.

Background Increasing concerns over the effectiveness and quality of continuing medical education (CME) programs has encouraged educators to use theoretically driven empirical research to improve the educational value of these activities. Within cognitive psychology, theories of learning and knowledge acquisition, such as test-enhanced learning (TEL), may be used to enhance the effectiveness of CME protocols and delivery. The present study examined whether the pedagogical benefits of testing can be observed in practicing physicians. Methods A total of 83 physicians were recruited following an education session on constipation management and were randomized to either (a) the test condition (n = 43), where learners wrote a short test consisting of 10 short-answer questions (SAQs), or (b) the study condition (n = 40), where learners studied the same information. Four weeks later, 56 (68%) physicians completed a final test with 10 new SAQs, with 27 being from the initial test condition and 29 belonging to the initial study condition. Results Performance on the final SAQ test was equivalent for both test (42.5%) and study-only (41.2%) conditions (p = .71). Discussion The null findings in the present study are inconsistent with previous research showing the pedagogical benefits of testing relative to studying. Given that most TEL research focuses on novice learners, who lack strong associative memory networks, it is possible that TEL is specific to novices and not generalizable to experts. Alternative explanations focus on the importance of repeated, distributed testing with feedback.

The addition of harmful adulterants to cocaine has become widespread in recent years and constitutes a novel etiological agent for disease. One agent in particular, the veterinary anthelmintic “levamisole,” has been increasingly used, owing to its potentiating effects of cocaine and its ability to pass crude methods of detection. Levamisole has been shown to cause a vasculitic syndrome of retiform purpura and skin necrosis, as well as leukopenia and autoantibody formation.

Objectives The purpose of this cadaveric study was to determine the proximity of the neurologic structures to the path of the screw inserted percutaneously into the ischial tuberosity. Design Cadaver study. Intervention Ten screws were inserted in 10 limbs (5 cadavers) under fluoroscopic guidance. Dissection was then performed to expose the head of the screw and was extended laterally to expose the sciatic nerve, the posterior cutaneous nerve of the thigh, and its inferior cluneal branches. Main outcome measure The distance from the screw head to the sciatic nerve, posterior cutaneous nerve of the thigh, and the inferior cluneal nerves. Results The distance from the center of the screw head to the sciatic nerve averaged 58 mm (range, 40-70 mm). The average distance between the screw head and the posterior cutaneous nerve of the thigh was 42 mm (range, 30-60 mm). The inferior cluneal branches were the closest to the path of the screw with an average distance of 3.5 mm in 6 specimens (range, 1-6 mm) and were injured by the screw in 3 and could not be located in another specimen. Conclusions The sciatic nerve and the posterior cutaneous nerve of the thigh appear to be safe during retrograde percutaneous screw fixation of a posterior column acetabular fracture through a central entry point in the ischial tuberosity. However, the inferior cluneal nerves that are responsible for the cutaneous sensitivity of the lower half of the gluteal region are at risk of injury.

Antibiotic spacers are an important tool in the management of periprosthetic joint infection. The concept of spacers has evolved from a static block in which the knee is immobilized in full extension to more conforming articulating surfaces that allow more knee motion, in an attempt to improve patients’ quality of life before and after reimplantation. Static spacers are still indicated in knees with significant bone and soft tissue compromise to avoid complications related to mobility in the absence of the proper amount of constraint. Increasing the amount of antibiotics added to the cement results in a higher and longer elution but could lead to potential systemic toxicity. It also reduces the mechanical strength of cement which becomes a concern if mobility and weight bearing are to be permitted. The ideal dose of antibiotics to be mixed with cement remains unclear. Large doses have been demonstrated to be clinically safe, but have not shown to be cost-effective in providing better infection control.

Revision arthroplasty is often required for confirmed cases of symptomatic tibiofemoral instability after total knee arthroplasty (TKA). We evaluated the results of revision for TKA instability in a consecutive series of 67 patients (68 knees) between 2000 and 2006. Outcome measures were surgeon-based assessment of knee stability, Knee Society Score, and Short Form Health Survey 36. At an average of 39 months of follow-up, the mean Knee Society Score and Short Form Health Survey 36 physical and mental scores were 76, 53, and 67 points, respectively. Knee instability persisted in 14 patients (22%). Data at the 95% confidence level revealed that revising both the femoral and tibial components, the use of femoral augments, and smaller joint line elevation as measured on radiographs correlated significantly with achieving a stable knee. In revision surgery for TKA instability, revision of both components and the use of femoral augments seem to offer the most predictable outcome.

Periprosthetic joint infection is one of the most dreaded and complex complications of total joint arthroplasty. Periprosthetic joint infection is now the major cause of failure following total knee arthroplasty1 and the third most common cause of failure following total hip arthroplasty2. It is estimated that the prevalence of periprosthetic joint infection may be on the rise3. A wide variety of pathogens are known to cause periprosthetic joint infection, with the majority of infections being caused by gram-positive bacteria, especially staphylococcal species4,5. The treatment of a confirmed periprosthetic joint infection often includes the need for surgical intervention, and two-stage exchange arthroplasty is the most common mode of surgical treatment in North America. Two-stage exchange arthroplasty relies on removal of all foreign material and insertion of an antibiotic-impregnated cement spacer for the purpose of delivering high doses of antibiotics locally in the interval of time between the resection arthroplasty and subsequent reimplantation. Periprosthetic infection with fungi, although rare, represents a diagnostic and therapeutic challenge to which clear guidelines have not yet been established. It is not known if the protocol for treatment of a bacterial periprosthetic joint infection can also be applied in the same manner to fungal infections. Patients with fungal periprosthetic joint infection are believed to be a different type of host with decreased cellular immunity, mostly due to an underlying cause of immunosuppression, such as malignant disease, drug therapies (antineoplastic agents, corticosteroids, or immunosuppressive drugs), overuse or inappropriate use of antibiotics, and indwelling catheters (urinary or parenteral hyperalimentation). Other factors, such as diabetes, tuberculosis, intravenous drug use, and acquired immunosuppressive disease, are associated with an increased frequency of mycotic infection6. The lack of reliable antifungal medications for systemic and, in particular, local delivery poses a real challenge …

Two-staged resection arthroplasty with delayed reimplantation is currently the method of choice for treatment of an infected total hip arthroplasty. There is paucity of data regarding the risk factors for reinfection after reimplantation. The objective of this study was to determine the efficacy of two-stage resection arthroplasty for infected THA and to identify risk factors for reinfection. The outcome of this procedure was evaluated in 54 consecutive patients at our institution from January 1999 to August 2005. The mean follow-up time for patients who were successfully treated was 32 months (range: 24 to 76 months). Infection with methicillin-resistant organisms occurred in 33 patients (61%). Recurrent infection was diagnosed in 14 patients (26%) after the second stage reimplantation procedure at an average of 10.6 months. An elevated ASA, which is an indicator of advanced comorbid health status, and infection with methicillin-resistant organisms were risk factors for treatment failure. An additional 8% of the cohort developed early mechanical failure at a mean of 13.8 months. The increase in the number of resistant organisms and the rise in the number of patients with comorbid conditions have compromised the efficacy of two-stage exchange arthroplasty. Hence novel techniques for the treatment of periprosthetic infection are desperately needed.

The success of open irrigation and debridement with component retention (ODCR) for acute periprosthetic knee joint infection varies widely. The species and virulence of the infecting organism have been shown to influence outcome. This multicenter, retrospective study identified 19 cases of acute periprosthetic methicillin-resistant Staphylococcus aureus (MRSA) knee infections managed by ODCR and at least 4 weeks of postoperative intravenous vancomycin therapy. At minimum follow-up of 2 years, the treatment failed to eradicate the infection in 16 cases (84% failure rate). Of those 16 failures, 13 patients required a 2-stage exchange arthroplasty, 2 patients required repeat incision and debridement with antibiotic suppression, and 1 patient died of MRSA sepsis. In addition, a systematic review of the literature revealed failure to eradicate infection in 10 of 13 patients managed with a similar protocol. The total success rate of ODCR in acute periprosthetic MRSA knee infection was 18%.

Erythrocyte sedimentation rate and C-reactive protein are common preoperative diagnostic markers for prosthetic joint infection but their prognostic role before reimplantation has yet to be defined. We therefore determined the prognostic value of erythrocyte sedimentation rate and C-reactive protein performed before second-stage reimplantation for the treatment of infected total knee arthroplasty (TKA). We studied 109 patients who had undergone two-stage revision TKA for sepsis from 1999 to 2006. Receiver operating characteristic curves were constructed to determine the discriminatory value of erythrocyte sedimentation rate and C-reactive protein before reimplantation in predicting persistent infection. Twenty-three of the 109 patients (21%) required revision surgery for recurrence of prosthetic joint infection. The receiver operating characteristic areas under the curve suggested erythrocyte sedimentation rate and C-reactive protein poorly predicted persistent infection after TKA reimplantation. Cutoff values could not be obtained because of the high variance. We reached similar conclusions regarding the change in erythrocyte sedimentation rate and C-reactive protein levels from time of resection. More accurate diagnostic tools are needed to support clinical judgment in monitoring infection progress and thus deciding whether to proceed with TKA reimplantation.Level II, therapeutic study.

Irrigation and debridement (I and D) is a procedure commonly used for the treatment of acute periprosthetic infection. This study retrospectively reviewed clinical records of patients with periprosthetic infection of the hip or knee who underwent I and D with retention of their prostheses between 1997 and 2005 at a single institution. One hundred four patients (44 males and 60 females) were identified. Mean age at time of initial debridement was 65 years. Average follow-up was 5.7 years. Treatment failure was defined as the need for resection arthroplasty or recurrent microbiologically proven infection. According to these criteria, I and D was successful in 46 patients (44%). Patients with staphylococcal infection, elevated American Society of Anesthesiologists score, and purulence around the prosthesis were more likely to fail. The high failure rate of this procedure implies that it should be preferably limited to select healthy patients with low virulence organisms and equivocal intraoperative findings.

The orthopedic community continues to face a challenge with regard to the prevention of thromboembolism after total joint arthroplasty. The first and foremost issue facing surgeons is how to select the best agent or modality that is effective in preventing the untoward consequences of thromboembolism without causing other complications that can have dire consequences. Other challenges include the uncertainty regarding the dose and duration of various agents, the value of mechanical prophylaxis alone, and the exact end points that should be used to measure the efficacy of prophylaxis. This article discusses some of the recent developments in prevention and management of thromboembolism after total joint arthroplasty, in particular highlighting the guidelines that were developed by American Academy of Orthopedic Surgeons.

Sixty Crossfire (Stryker Orthopaedics, Mahwah, NJ) liners were consecutively revised after an average of 2.9 years (range, 0.01-8.0 years) for reasons unrelated to wear or mechanical performance of the polyethylene. Femoral head penetration was measured directly from 42 retrievals implanted for more than 1 year. Penetration rate results (0.04 mm/y, on average; range, 0.00-0.13 mm/y) confirmed decreasing wear rates with longer in vivo times. Overall, we observed oxidation levels at the bearing surface of the 60 liners (0.5, on average; range, 0.1-1.7) comparable to those of nonimplanted liners (0.5, on average; range, 0.3-1.1) and preservation of mechanical properties. We also measured elevated oxidation of the rim (3.4, on average; range, 0.2-8.8) that was correlated with implantation time. Rim surface damage, however, was observed in only 3 (5%) of 60 cases. Retrieval analysis of the 3 rim-damaged liners did not reveal an association between surface damage and the reasons for revision.

Fully porous-coated cementless implants have a low failure rate and excellent survivorship in primary and revision surgery. Failure secondary to implant fracture is extremely rare with modern implant designs. We report an early fracture of a fully porous-coated femoral stem after primary total hip arthroplasty. The implant failed because of a filling mismatch between the proximal and distal femur.

Introduction: Revision of total knee arthroplasty (TKA) is known to be an effective procedure in its ability to relieve pain and improve function. Currently there are numerous instruments for measuring patient outcome. The most popular physician based scale is the Knee Society Score (KSS). Other forms that assess the patient’s perception of quality of life are the Short Form Health Survey (SF-36), the Western Ontario McMaster Arthritis Index (WOMAC), and a 4-Question 4-Point Likert Scale for Patient Satisfaction. The purpose of the study was to determine the correlation of the surgeon’s assessment of outcome after revision surgery to that of the patient’s.

Introduction: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are popular preoperative diagnostic markers for prosthetic joint infection (PJI) with well delineated cut-off values. The prognostic role of serology prior to reimplantation has yet to be defined. The current study aims to determine the prognostic value of ESR and CRP performed prior to second stage reimplantation for the treatment of infected TKA.

The addition of harmful adulterants to cocaine has become widespread in recent years and constitutes a novel etiological agent for disease. One agent in particular, the veterinary anthelmintic “levamisole,” has been increasingly used, owing to its potentiating effects of cocaine and its ability to pass crude methods of detection. Levamisole has been shown to cause a vasculitic syndrome of retiform purpura and skin necrosis, as well as leukopenia and autoantibody formation.