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Biomedical subjects

Robert L Barrack

Publications and source records attributed to Robert L Barrack.

At least 19 recordsLinked to original sources
PubMed2006

Effect of duty hour standards on burnout among orthopaedic surgery residents.

We surveyed orthopaedic surgery residents and faculty from two university training programs to quantify quality of life measures including burnout, general health, and relationship issues. Residents exhibited high levels of burnout and emotional exhaustion but only average levels of personal achievement, while faculty showed lower levels of burnout and emotional exhaustion with above average scores for personal achievement. Resident burnout was positively correlated with number of hours worked while faculty hours worked was inversely related to burnout. The survey was readministered two years after implementing the Accreditation Council on Graduate Medical Education guidelines on residency duty hours. At this time resident scores for personal accomplishment had improved, while scores for emotional exhaustion showed a strong trend towards decreasing, and depersonalization scores also showed a possible trend towards decreasing. Resident duty hour limitation was associated with improvement in objective measures of burnout.

Adult↗
PubMed2006

Revision total hip arthroplasty: the patient's perspective.

We evaluated a consecutive series of patients followed for at least 1 year after revision total hip arthroplasty. We surveyed 488 patients treated at three referral centers from 1998 to 2002. An experienced medical interviewer contacted patients and rated their degree of satisfaction with the original and revision arthroplasties, the reason of original arthroplasty failure, and their expectations for revision arthroplasty longevity. Surveys were completed on 320 of the 488 patients (66%). A member of the research team reviewed patients' operative reports, clinical records, and radiographs to determine the diagnosis at revision, procedure performed, and the most likely cause of failure. Patient satisfaction with the primary procedure was directly related to the time to revision. Most patients (214 of 320; 67%) expected their revision to last longer than their primary arthroplasty regardless of revision diagnosis or how long the primary procedure lasted before revision. The surgeons' failure assessments agreed with the patients' failure assessments only 36% of the time. Although the majority of patients (262 of 320; 82%) were satisfied with the results of the revision procedure, most did not agree with their surgeon as to why the original arthroplasty failed, and most had unrealistic expectations regarding revision longevity.

Arthroplasty, Replacement, Hip↗
PubMed2006

Resection arthroplasty: when enough is enough.

Resection arthroplasty following THA is rarely performed but occasionally indicated. It is a relatively low risk procedure and generally is a much shorter operative procedure associated with fewer perioperative complications compared to major revision procedures. Results are extremely variable. With all of the arthroplasty and bone graft options available for hip joint reconstruction, resection arthroplasty rarely is performed as a definitive procedure. It is, however, the best option for selected patients.

Arthroplasty↗
PubMed2006

Preoperative planning for revision total hip arthroplasty.

Revision total hip arthroplasty is associated with more perioperative complications and unexpected findings than are encountered during primary total hip arthroplasty. Special instruments, implants, bone grafts, and other accessories may be required to treat complex problems that arise during revision surgery. Preoperative planning is important to anticipate potential complications and to ensure that all possible needed materials are readily available during surgery. Patients and their families also should be counseled on the specific additional risk factors involved in this complex surgery. An organized approach to revision total hip arthroplasty helps to reduce surgical time, minimize risks, decrease the stress level of the entire surgical team, and to increase the rate of successful outcomes for patients.

Arthroplasty, Replacement, Hip↗
PubMed2005

Bone graft extenders, substitutes, and osteogenic proteins.

A number of products that serve as a bone graft substitutes or graft extenders are currently available. Osteoconductive products provide a porous 3-dimensional structure that encourages bone ingrowth. These materials are readily resorbed by osteoclasts leading to turnover into host bone at variable rates. Some calcium phosphate products act as cements in that they are liquid upon preparation and harden at body temperature. These cements resist compressive forces but are not effective in resisting shear or torsion. Calcium sulfate resorbs more quickly than calcium phosphate and has the potential to serve as a carrier for drugs or growth factors. Preclinical studies have shown that the osteoinductive capacity of autograft and allograft bone can be improved substantially with the addition of osteogenic proteins. Although no detailed clinical studies have been reported to date, anecdotal reports of their use with and without bone graft indicate results consistent with those obtained in preclinical studies.

Bone Cements↗
PubMed2005

Current status of trochanteric reattachment in complex total hip arthroplasty.

UNLABELLED: A study was done to determine if cable fixation devices of more recent design were associated with a higher success rate and lower incidence of complications compared with early cable devices. Beginning in 1997 a cable plate device was used in an attempt to restore abductor function more consistently in complex total hip arthroplasties. Cobalt-chrome cables through holes in a trochanteric cable plate with two or more transversely oriented cables at or below the lesser trochanter were used in order to resist migration of the trochanteric fragment better. Other component features included instrumentation that allowed provisional fixation and measurement of the tension in the cables so that cables could be tightened and retightened sequentially to insure a minimum of 80 inch-pounds of tension in all cables before final crimping. Minimum 2-year followup was obtained in 42 patients who had complex arthroplasties (trochanteric nonunions and reattachment to structural grafts) in which such a device was used. Clinical and radiographic results were compared with a series of patients with similar indications in whom wire or and earlier-generation trochanteric cable fixation devices were used. The cable plate of a more recent design was associated with a possible trend for a lower incidence of limp, use of assistive walking devices, dislocation, and abductor weakness and significant decrease in the incidence of breakage and trochanteric nonunion. LEVEL OF EVIDENCE: Therapeutic study, Level III-1 (retrospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Arthroplasty, Replacement, Hip↗
PubMed2004

Neurovascular injury: avoiding catastrophe.

Major neurovascular injury is the least common, but most distressing, complication of total hip arthroplasty (THA). The keys to minimizing the incidence of these complications are recognizing patients at risk and knowledge of the relevant anatomy. Partial sciatic palsy is the most common nerve injury. At least partial recovery can be expected in 70% to 80% of cases, with the remainder frequently displaying dissatisfaction with their surgery. Vascular injury is most frequently associated with the use of screws for fixation of structural grafts, acetabulur components, and protrusio rings or cages. An understanding of the acetabular quadrant system is crucial in minimizing these potentially catastrophic complications.

Arthroplasty, Replacement, Hip↗
PubMed2004

Winner of the 2003 James A. Rand Young Investigator's Award. Early failure of cementless mobile-bearing total knee arthroplasty.

A consecutive series of 82 cementless mobile-bearing total knee arthroplasties performed was studied to determine the reliability of cementless tibial component fixation. The indications for surgery in all cases were osteoarthritis with only mild or moderate deformity. Evaluation consisted of a Knee Society clinical score (KSCS) and radiographic evaluation preoperatively and at annual follow-up. Minimum 2-year follow-up was obtained in 73 of 82 knees (89%). Results were compared to those of a subsequent consecutive series of 76 knees (66 with 2-year follow-up) performed with a mobile-bearing TKA with cemented components with the same indications, implant, technique, and length of follow-up. Six of 73 cementless mobile-bearing TKAs (8%) underwent tibial component revision for symptomatic subsidence and failure of ingrowth compared to 0/66 revisions in the cemented group (P<.05). Patients with cementless mobile-bearing TKA also had a significantly lower KSCS (161 versus 184, P<.05), significantly higher incidence of pain rated more than mild (23% versus 7%, P<.01) and a trend toward less arc of motion (106 degrees versus 115 degrees, P<.2). The results do not support the hypothesis that mobile-bearing TKA imparts the advantage of reliable tibial bone ingrowth.

Arthroplasty, Replacement, Knee↗
PubMed2004

The effect of stem design on end-of-stem pain in revision total knee arthroplasty.

A series of 143 revision total knee arthroplasties was evaluated using a Knee Society clinical score, radiographic assessment, and satisfaction questionnaire. Patients completed a pain drawing showing the location and severity of pain they experienced at 2 years follow-up. Two stem designs were used: a solid, fluted cobalt chrome stem (group I) and a slotted titanium stem (group II). End-of-stem pain was associated with solid cobalt chrome stems while a lower incidence of stem pain was associated with slotted titanium stems. Symptoms were intermittent and activity related in all but 2 cases, but none required component revision. The presence of end-of-stem pain did appear to be clinically significant because patients with this pain were more likely to be only somewhat satisfied or dissatisfied with their degree of pain relief compared to those without end-of-stem pain. Stem design does appear to impact the incidence of end-of-stem pain in revision total knee arthroplasty.

Arthroplasty, Replacement, Knee↗
PubMed2004

Preoperative planning for revision total hip arthroplasty.

Perioperative complications and unexpected findings at surgery are much more common in revision total hip arthroplasty (THA) compared with the primary setting. The surgeon often is faced with problems during surgery that require special instruments, implants, bone grafts, or other accessories that frequently are not available unless the potential need for these items was anticipated during the preoperative planning process. Anticipation of possible complications also is crucial in the process of informed consent. Patients should be counseled regarding the specific additional risks they face. Preoperative planning is the first and probably the most important step in doing revision THA. An organized approach helps shorten the operative time, minimize risk, decrease the stress level of the surgeon and operative team, and increase the success rate of these complex cases.

Arthroplasty, Replacement, Hip↗
PubMed2004

Intraoperative complications of revision hip arthroplasty using a porous-coated, distally slotted, fluted femoral stem.

Intraoperative complications of 175 cementless revision total hip arthroplasties done at four institutions using a porous-coated, uncemented, distally slotted, fluted femoral stem were reviewed. Three types of complications were recorded: eccentric reaming, femoral perforation, and femoral fracture. Intraoperative complications occurred in 16 patients (9.1%). There was no statistically significant association between complication rate and type of surgical approach, stem length, stem diameter, or host bone quality. This complication rate is comparable to or lower than that reported with the use of similar uncemented long femoral revision stems.

Adult↗
PubMed2004

Osteogenic protein-1 in knee arthritis and arthroplasty.

The use of graft materials to restore bone stock and promote healing and implant stabilization is a crucial part of total knee arthroplasty, especially in revision surgery. Recent research has centered on the use of osteoinductive materials to promote bone formation. Osteogenic proteins are members of a superfamily of proteins called transforming growth factor-beta that, either alone or in combination with other regulatory molecules, induce new bone formation. The cloning and genetic expression of recombinant human osteogenic proteins has led to production of quantities sufficient for their clinical use. Recombinant human osteogenic protein-1 has been combined with bone-derived Type I collagen for delivery to an implant site. Preclinical studies have shown that the osteoinductive capacity of autograft and allograft bone and bone graft substitute materials can be notably improved with the addition of osteogenic protein-1. The use of this protein consistently improved the amount and rate of new bone formation compared with graft alone, resulting in earlier graft incorporation and consolidation. In addition, because osteogenic proteins are chondrogenic, they also may have a role in the treatment of cartilage injury and degeneration. Osteogenic protein-1 has been shown to induce hyalinelike cartilage repair of full thickness osteochondral defects in animal models with no degradation of the tissue with time. Although no detailed clinical studies in knee surgery have been reported with the use of osteogenic protein-1, in anecdotal cases its use alone and with bone graft materials indicate results consistent with those obtained in preclinical studies.

Arthroplasty, Replacement, Knee↗
PubMed2004

Concerns about ceramics in THA.

Currently available ceramic materials are superior to those used originally in total hip arthroplasty, which should translate into a much lower complication rate than what has been reported previously. In spite of this, a number of concerns remain. The ceramic-on-ceramic articulation is not immune to wear and surface damage. Conditions associated with ceramic wear include vertical cup position, femoral neck impingement, and femoral head separation. A unique pattern of stripe wear has been described as something that results from microseparation during gait. Catastrophic failure, although rare, continues to be a concern, and not all fractures can be predicted by proof testing. Revisions needed because of ceramic fractures can be extensive, and the results of the revision procedures can be compromised by the presence of highly abrasive particulate debris that is retained. Other concerns include the generation of debris from modular interfaces, neck damage and debris generation from impingement of some designs, inability to use a ceramic head a second time on a metal trunnion, and the dramatic loss of head and liner options intraoperatively. Although ceramics show great promise as a lower wear articulation, manufacturing and design modifications and improvements will continue in an attempt to address the substantial concerns that persist.

Ceramics↗
PubMed2004

Stress and coping among orthopaedic surgery residents and faculty.

BACKGROUND: Evaluations of physicians and residents have revealed concerning levels of psychosocial dysfunction. The purposes of this study were to determine the quality of life of orthopaedic residents and faculty and to identify the risk factors for decompensation. METHODS: Twenty-one orthopaedic residents and twenty-five full-time orthopaedic faculty completed a 102-question voluntary, anonymous survey. The survey consisted of three validated instruments, i.e., the Maslach Burnout Inventory, the General Health Questionnaire-12, and the Revised Dyadic Adjustment Scale; and three novel question sets addressing background and demographic information, stress reaction and management, and the balance between work and home life. Descriptive statistics, pairwise correlations, simple t tests, and Pearson and nonparametric Spearman correlations were calculated. The simple correlation coefficient was used to assess bivariate relationships. RESULTS: The mean overall quality-of-life score, on a scale of 0 to 4 points, was 2.5 points for residents compared with 3.6 points for faculty members. Residents reported considerable burnout, showing a high level of emotional exhaustion and depersonalization and an average level of personal achievement, whereas faculty reported minimal burnout, showing a low level of emotional exhaustion (p < 0.0003), an average level of depersonalization (p < 0.0001), and a high level of personal achievement (p < 0.0001). Only two of twenty-five faculty members (compared with seven of twenty-one residents) scored over 4 points on the General Health Questionnaire-12, indicating significant symptomatology (p < 0.01). The majority of subjects reported that a partner or spouse showed nondistressed levels of marital adjustment and satisfaction. All residents and nine of the twenty-five faculty members had mentors but judged the resource to be minimally beneficial. Resident burnout and psychiatric morbidity correlated with weekly work hours; conflict between the commitments of work and home life; discord with faculty, nursing staff, and senior residents; debt load; and work-related stress. Protective factors included being a parent, spending time with a spouse, having a physician father, and deriving satisfaction from discussing concerns with colleagues, friends, and family. CONCLUSIONS: In pursuit of our goal of determining the quality of life of orthopaedic residents and faculty, we identified a large disparity between the two groups. The resident group reported much greater levels of dysfunction particularly with regard to burnout and psychiatric morbidity. Furthermore, with regard to our second goal; our data revealed a number of risk factors for resident decompensation, most notably, increased workload, high debt levels, and discord with superiors. In addition, our research revealed that the current support interventions by the residency program, including mentoring and facilitation of spousal adjustment, are viewed as being of little help.

Adaptation, Psychological↗