Browsing by Author "Webb, Brian"
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Item EVALUATION OF INTRAOPERATIVE LIGAMENT INJURY DURING TOTAL KNEE ARTHROPLASTY INVOLVING RESIDENT TRAINING(2014-03) Joseph, Ryan; Wagner, Russell; Webb, BrianThe purpose of this study is to evaluate if the operative experience level of residents affects the incidence of ligament injuries in patients who have received a total knee arthroplasty. Purpose (a): The focus of this study was to evaluate intraoperative errors in the performance of total knee arthroplasties (TKAs) and compare the error rate of when a junior resident versus a senior resident served as the primary surgeon. Methods (b): A restrospective analysis was performed on all of the TKAs performed by either a junior or senior resident, directly supervised by Russell Wagner, MD, over a four year period of time. This study identified 346 cases, 143 of which were performed by a junior resident and 203 of which were performed by a senior resident. Incidence of injury was also evaluated to determine if intraoperative errors occur as frequently throughout a given rotation or if the occurrences decreased as the rotation progressed. In addition to this, differences between rotations taking place at the beginning of the year and rotations occuring at the end of the year was also investigated. Finally, the last factor analyzed was whether there was a correlation between a patient’s BMI and a ligament injury. Results (c): Of the 346 total knee arthroplasties performed from January 1, 2008 to December 31, 2012, there was an incidence of ligament injury in 7.5% of the cases. The occurrence of injury in which junior residents performed the surgery was 6.3%, compared to 8.3% when senior residents performed the surgery. There were no significant differences between junior or senior residents performing the surgery with regards to intraoperative ligament or tendon injury (p=. 58). The most common ligament injured was the medial collateral in 11 (3%); other ligament injuries included the posterior cruciate ligament in 10 (3%), the patellar tendon in 3 (1%), the popliteus tendon in 2 (.5%), and the lateral collateral ligament and iliotibial band in 1 (.3%). There was no relationship between ligament/tendon damage and in which month of the rotation the surgery was performed. There was also no correlation between rotations during the beginning versus the end of the year. 1 ligament/tendon injury occurred in 89 patients (1%) with a BMI of 30 or less while 25 ligament/tendon injuries occurred in 257 patients (10%) with a BMI of more than 30. This difference was statistically significant (p=.034). Conclusions (d): This analysis suggests that supervised junior residents may safely play a more active role when performing total knee arthroplasty since their involvement is not associated with increased intraoperative ligament or tendon injury. This information may assist attending orthopaedic surgeons and resident training programs in determining the role of junior residents during surgery.Item Implementation of a Pre-Operative Huddle at a Level 1 Trauma Center(2021) Rechter, Griffin; Scofield, Harrison; Webb, BrianPurpose: Medical errors resulting in patient harm occur frequently. Surgery is a high-risk specialty that requires standardization of communication and processes to decrease errors. We sought to determine whether the implementation of a pre-operative huddle could improve communication and decrease medical errors. Methods: A pre-operative huddle was developed and implemented at a level 1 trauma center. The hospital database was used to review data before and after the huddle implementation. We analyzed patient surveys and comments, percentage of on-time OR starts, OR turnover times, and number of sentinel events. Statistical analysis was performed using chi-square testing for OR start time differences, and the Mann-Whitney U Test was used to compare turnover time and delayed starts. Results: After implementation, we observed a trend of improvement in patient survey results regarding patients' perception of overall understanding following the explanation of their procedure by the healthcare team, p< 0.001. There was an increase in on-time OR starts from 37% to 42%, p< 0.001. Notably, there was a statistically significant increase in OR turnover time from 38 minutes to 40 minutes. We also observed a decrease in the number of sentinel events. Conclusions: We found that implementing a pre-operative huddle at a large level 1 hospital improves patient safety, on-time OR starts, and communication amongst the healthcare team, without significantly disrupting OR workflow. Use of standardized communication processes may contribute to a decrease in medical errors and assist hospitals in becoming highly reliable organizations.Item Implications of Interactive Online Medical Education for TCOM Musculoskeletal Education(2023) Crowther, Jacqueline; Frangenberg, Alexander; Nesterenko, Alissa; Maharjan, Laura; Meyer, Kim; Webb, BrianPurpose: In the modern medical curriculum, students are required to learn increasing amounts of information, and the ability to adapt and expand the threshold of fundamental concepts is becoming increasingly important. Most recently, the COVID-19 pandemic has forced the medical education system to adapt to a new challenge - delivering a comprehensive medical education to students remotely without compromising the quality of education. As a result, online interactive learning modules were introduced into the second exam portion of the TCOM Musculoskeletal Systems 2 (MSS2) course. This study aims to retrospectively review the effects of this online, interactive, module-based format. Methods: A retrospective review was performed to compare student performance before and after the implementation of these pandemic related changes. De-identified student data (n=685) from the 2019 pre-pandemic cohort and the 2020 and 2021 post-pandemic cohorts were utilized for the study. The dataset included student cumulative medical school GPA prior to the beginning of the course, class quartile rank, MSS2 exam scores and final course grades. Standard post-course surveys were utilized for the qualitative portion of the analysis, and an additional course satisfaction survey administered via google polls was added for the purpose of collecting anonymous student feedback and suggestions for improvement. Quantitative analysis was conducted on parametric and non-parametric variables. For parametric variables, the independent sample T-test was utilized to assess significant differences in a number of different variables, including both broad and specific statistical questions regarding the data. Results: The implementation of the online musculoskeletal modules correlated to a significant difference between the course grades of the 2019 and 2020 cohorts with mean scores of 88.4 and 87.2 respectively (p=.025). A significant improvement was found in the second exam for the 2019 and 2020 cohorts (p=.006), whereas no significant difference was revealed between the first exam grades of the two cohorts (p = 0.49). The data analysis from the two years following the pandemic demonstrated a successful implementation of online modules with the significant improvement of exam grades in the second exam where the modules were incorporated, including in the 2021 cohort. These significant findings indicate a benefit of introducing such modules into the second exam. Post-course surveys revealed that 57% of students want to see interactive modules in future courses, with an additional 28% being neutral. Conclusions: The addition of interactive modules to the MSS2 curriculum was beneficial as students were able perform significantly better on the relevant exam material despite entering the course with significantly lower GPAs. Furthermore, the majority of students responded positively to the possibility of seeing interactive modules used in future courses.Item A Missed Case of Synovial Osteochondromatosis(2024-03-21) Alkhabbaz, Omar; Bibi, Yasser; Webb, Brian; Milhoan, MadisonBackground: Synovial osteochondromatosis is a benign, uncommon, and interesting disorder that presents challenges in diagnosis and treatment. It is a complication of the synovial membrane of joints, tendon sheath, and bursae that can cause dysfunction most commonly in the knee, hip, or shoulder that has the potential of transforming into chondrosarcoma. While the exact etiology of a primary synovial osteochondromatosis is still in question, hypotheses point toward the metaplasia of the synovial membrane and the detachment of cartilaginous fragments as potential causation. The cause of secondary synovial osteochondromatosis is associated with an underlying joint pathology or condition that triggers development such as osteoarthritis, rheumatoid arthritis, or traumatic joint injuries Patients with this condition usually present with a history of pain in the joint affected, swelling, crepitus, and limited range of motion (ROM).The pain is usually aching in nature and is exacerbated by weight-bearing activities such as prolonged periods of walking or standing. Case Information: A 62-year-old female with a past medical history of hypertension and hypothyroidism presented to the clinic with a chief complaint of bilateral knee pain and effusions, which was diagnosed as osteoarthritis based on clinical exam and past X-rays. The patient had been experiencing moderate relief from bilateral steroid injections that were administered approximately every four to six months. As for diagnostic imaging, she had two MRI scans of her left knee; the first in 2020 and the second in 2023. The differential diagnosis formulated in the clinic after the MRI scan (Fi [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10705034/figure/FIG1/]was pigmented villonodular synovitis (PVNS), rheumatoid arthritis (RA), or synovial chondromatosis. Conclusions: Although synovial osteochondromatosis is generally a benign condition, transformation to chondrosarcoma is still a possibility. Imaging may assist in identifying the loose bodies floating in the joint space, but this becomes much more difficult if the loose bodies are radiotransparent (chondromatosis). Calcified nodules (osteochondromatosis) are relatively less difficult to view on X-ray. T2 weighted MRI imaging can help identify synovial hyperplasia which can help clue clinicians in with other physical exam findings. Although an arthroscopy with histopathology is the gold-standard diagnostic modality, it is important to keep in mind that one or even two different types of imaging modalities may not be sufficient for synovial osteochondromatosis to make the differential. As seen in our case, it took three years after the pain from the onset of chondromatosis for suspicion to arise on MRI. Sometimes patients may not be so fortunate by the time it is noticed and, although uncommon, the formation of chondrosarcoma may already be in progress. If left untreated, patients can also develop severe osteoarthritis. Clinicians must not hesitate to diversify the imaging modalities in which they order, as a diagnosis may become more apparent in one versus the other. Another lesson to take from our case is to stay vigilant in regard to who can present with synovial osteochondromatosis. Although our patient did fit the expected location of the disease (larger joint, the knee in this case), she did not fit the expected gender or age group in which these processes arise.Item Online learning modules improve musculoskeletal medicine exam scores(2021) Mirochnitchenko, Alissa; Garcia, Laura; Webb, Brian; Meyer, KimPurpose: Effective teaching methods are fundamental in ensuring medical student success. In the spring of 2020, the pandemic forced most medical school courses to go online. As a result, online interactive learning modules were introduced into the second exam portion of the TCOM Musculoskeletal Systems 2 (MSS2) course. This study aims to retrospectively review the effects of this online, interactive, module-based format. Methods: Student demographics, course grades and student course feedback from the MSS2 course in spring of 2019 and 2020 were collected and analyzed using a mixed-methods approach. A quantitative analysis was conducted using SPSS to determine if there was a difference in course outcomes between the 2019 cohort and 2020 cohort. Additionally, a qualitative analysis was conducted to compare student feedback between the cohorts. Results: Although the final grade for the MSS2 course was statistically significantly higher in the 2019 cohort (88.4% vs. 87.2%), the 2020 group achieved a significantly higher average grade for the second exam of the course in which online modules were added (88.1% vs. 86.3%). A significantly smaller proportion of the 2020 cohort scored below 80% on the second exam (11.66% vs. 18.34%). Most comments regarding the modules were positive. Conclusions: The addition of interactive modules to the MSS2 curriculum was beneficial as students were able perform significantly better on the relevant exam material despite entering the course with significantly lower GPAs. Furthermore, student feedback about their learning was positive.Item Reduction Technique in a Rockwood Grade VI Acromioclavicular Separation(2017-03-14) Payne, Joshua; Webb, Brian; Schaefer, TravisHypothesis and Purpose: Rockwood Grade VI acromioclavicular separations (AC) are extremely rare injuries and pose a challenge because the surgeon must reduce the clavicle to its appropriate anatomical position from the subcoracoid or subacromial space. After searching the literature, there is scant information of the appropriate reduction technique. This report aims to describe the reduction technique as well as the appropriate ligament reconstruction technique. Materials and Methods: A 35 year old female was involved in a rollover motor vehicle crash with ejection. The patient presented to the ED with multiple facial lacerations, closed nasal fracture, a closed displaced left scapula fracture, a closed right ulna fracture, and a Rockwood Grade VI AC separation. She presented with severe left shoulder pain as well as numbness over the medial aspect of her forearm. We present our case of distal clavicle excision, reduction, and reconstruction of the coracoclavicular ligaments. Results: The reduction was performed by placing a lobster claw clamp around the clavicular shaft to control the clavicle. A cobb elevator was used in a lever-like fashion to free the clavicle from the inferior coracoid. Soft tissue adhesion from the pectoralis minor and the anterior deltoid insertion were free with bovie electrocautery. A curette was used to sweep the pectoralis minor and the conjoined tendon off the clavicle as well as to cup the posterior inferior edge of the clavicle. Anterior and superior force was exerted on the clavicle until the clavicle was reduced into anatomic position. The distal clavicle was excised and the coracoclavicular ligament was reconstructed with a semitendinosis allograft. The patient's pain was improved post-operatively compared to pre-operatively and her pre-operative numbness was immediately resolved post-operatively. Conclusions: Rockwood grade VI AC separation is a rare injury without a clear reduction technique. We present a reduction and fixation technique that was successful in improving our patients pain and her pre-operative numbness.Item Rotational Alignment in the Coronal Plane During Tibial Tubercle Osteotomy Background & Significance(2017-03-14) Webb, Brian; Gonzales, GabrielSignificance & Hypothesis: Prior literature has demonstrated the effects of translation of the tibial tubercle during tibial tubercle osteotomy (TTO) procedures in both the sagittal and transverse planes but there has not been much investigation into the effects of adjustment of the rotation alignment of the tibial tubercle in the coronal plane. Since changes in the positioning of the tibial tubercle in all three planes has the opportunity to yield significant physiological changes in range of motion, the results of this study would possibly provide insight on how to optimize this procedure. Specifically, a margin of error determination may be made from the data to guide surgeon fixation of the tubercle post osteotomy. This study is aimed at the effects of variations to the tibial tubercle in the TTO procedure, specifically investigating effects of rotational alignment of the tibial tubercle in the coronal plane. The hypothesis of this study is that coronal plane rotation during TTO must be within 5 degrees of native orientation to prevent poor patellofemoral kinematic effects. Materials & Methods: At least 10 frozen, fresh, prepared specimens would have the musculature of the thigh exposed with specific muscles sutured to accommodate loads of weight specific to each muscle type to achieve standardized range of motion. The specimens would be secured into a knee-rig structure allowing full flexion and extension. Each specimen would be initially range of motion tested and used as control for comparison to the resulting range of motion after the TTO is performed. A tracking system will be utilized, recording patellar range of motion data with 6 degrees of freedom during leg range of motion testing cycles. For each specimen, initial native patellar motion would be documented, and then compared against resultant patellar motion as the degree of tibial tubercle rotational alignment in the coronal plane is incrementally adjusted. Comparison will involve evaluation of the Euler angle changes of the native patella against measurements as the rotational alignment is adjusted. A repeated one-way ANOVA will be used with a post hoc tukey test to find statistical significance. Results: Pathologic rotational motion of the tibia on femur has been noted grossly with alterations of coronal alignment of the tibial tubercle, especially at the end range of extension. Detailed statistical analysis is currently pending on gathered data. Conclusions: Rotational alignment modification of the patellar tendon insertion, the tibial tubercle, causes unilateral unloading and loading of the quadriceps musculature. This change in force vectors results in gross change to lower extremity flexion and extension mechanics. Further data analysis is required to make specific comments on the details of this change.Item Sleep Duration and Social Determinants of Health Predict Osteoporosis in Adults 50 Years of Age and Older After Controlling for Vitamin D, Demographic Characteristics, and Physical Activity.(2023) Campbell, Blake; Fulda, Kimberly; Zhang, Fan; Webb, Brian; Espinoza, Anna; Navid, DanielPurpose: Osteoporosis is a bone disease that develops when bone density and mass decreases, or when the quality or structure of bone changes. There are many causes of osteoporosis, with some etiologies being more understood than others. Prevention is critical in the treatment of osteoporosis, due to its serious complications, including life altering hip and spine fractures. Despite prevention and treatment, osteoporosis in most cases is inevitable, but the onset and severity is what can be helped. Finding other ways to slow or even prevent osteoporosis is an active area of study, with sleep being one of the many variables of interest due to its role in homeostasis. The literature demonstrates contradictory findings for the relationship between sleep and osteoporosis. Many of the studies lack a recent and/or big enough sample size, and there is a need for further research on the subject. Additionally, recent literature has not included variables representative of social determinants of health, such as income and education. The purpose of this study was to further investigate the association that between sleep and osteoporosis in individuals 50 and older using the NHANES Database while controlling for potential covariates such as social determinants of health. Methods: Data from the National Health and Nutrition Examination Survey (NHANES), 2017-2020 were analyzed to determine the association between sleep duration and osteoporosis in adults 50 and older. Multivariate logistic regression was performed controlling for race/ethnicity, age (≥50 years), gender, highest household education, physical activity, poverty, vitamin D, and BMI. Analyses were considered statistically significant at p<0.05. Results: Analyses included 4963 adults over the age of 50, with 51% (2507) being female. A total of 12.3% (611) of the cohort had a diagnosis of osteoporosis, with 87% of the osteoporotic group being female (530). Mean age was 65.2 years (sd=9.3) for the total sample, 64.5 (sd=9.2) for non-osteoporotic individuals, and 70.0 (sd=8.8) for osteoporotic individuals. In the adjusted analyses, we found no statistically significant association between sleep duration and osteoporosis. There is a statistically significant association between family monthly poverty level and osteoporosis ([OR:0.93; 95%CI(0.87-0.99) p=0.047]. BMI, Age, and Gender were also significantly associated with osteoporosis. Other social determinants of health such as race, physical activity, and education were not statistically significant. Vitamin D was also not associated with osteoporosis. Conclusion: The purpose of this study was to further investigate the association between sleep and osteoporosis in individuals 50 and older while controlling for covariates, particularly social determinants of health. We looked at specifically sleep duration, and a previous diagnosis of osteoporosis. We theorized that lower sleep durations may have an association with osteoporosis; however, our results did not support this. The association between family poverty index and osteoporosis highlights the importance of exploring socioeconomic differences in sleep and osteoporosis research in the future, respectively. Finally, this study is limited by a lack of a quantitative measure of osteoporosis. Future work with additional socioeconomic variables and more consistent data collecting modalities should shed more light on the subjectItem The Effect of ACL Femoral Drilling on Posterolateral Corner Reconstruction(2016-03-23) Webb, Brian; Marsh, Paul; Stout, EvanPurpose: This study aimed to evaluate the risk of tunnel collision with combined posterolateral corner (PLC) and anterior cruciate ligament (ACL) reconstruction and to identify which technique reduces the risk of tunnel collision. Methods: LCL and popliteus tunnels were drilled in sixty-four medium and large synthetic femurs and sixteen synthetic knee joints. ACL tunnels were then drilled using four different techniques: transtibial, anteromedial portal with a rigid guide pin, anteromedial portal with a flexible guide pin, and outside-in. The samples without obvious tunnel collision then underwent CT scan with 2-mm slices to determine the closest distance between the tunnels and the tangential distance (mm) between them were recorded. Results: Overall frequency of tunnel collision was 24/32 (75%) in large femur specimens and 32/32 (100%) for medium femur specimens. Obvious tunnel collision was observed in all transtibial, anteromedial with flexible instruments, and anteromedial with rigid instruments regardless of femur size or side. All of the specimens without tunnel collision occurred in the large femurs from the outside in group (n=8). The mean tunnel separation in all samples was 1.93 mm, with a range of 1.06 mm to 2.54 mm. Conclusion: Consistent with previous studies, we found a high rate of collision, especially in medium size femurs. The results of our study have provided evidence for the use of outside-in ACL reconstruction and PLC with 2 lateral femoral tunnels with the least amount of collision risk.