bluuebunny/crossref_metadata_2025 huggingface dataset:
Euro Zone and the Development of the Corporate Debt Market
Authors: Mills Roger
Published: May 2017

The European Union has recently expanded to include many former Eastern Bloc countries. This has lead to a decrease in average GDP per capita, but an increased overall market. The impact of this expansion (positive or negative) is still unclear and in this Manager Update, Roger Mills explores the consequences of this expansion, with a particular focus on the Corporate Debt Market.
Creating Sustainable Advantage
Authors: Turner Ian
Published: May 2017

How can organisations develop and implement strategies that are successful and sustainable over time? How can they avoid adopting strategies that will dissipate their advantage? In this Manager Update, Ian Turner reviews literature that suggests that a focus on human and technological resources holds the key to sustainable advantage.
Brand Valuation
Authors: Mills Roger
Published: May 2017

The financial success of many businesses is said to lie in the value of their brands. But how can managers put a financial value on their brands and those of other businesses? In this Manager Update, Roger Mills reviews the latest methodology used to value brands in financial terms and identifies their strengths and weaknesses.
Diversification: When to and When not to
Authors: Turner Ian
Published: May 2017

Is diversification good or bad for your company? Does it destroy or add to shareholder value? And what types of diversification are appropriate to different companies? Ian Turner answers these questions and gives some practical tips for managers considering a diversification strategy.
Financial Reporting and Financial Economics Draw Closer
Authors: Mills Roger
Published: May 2017

The introduction of the International Financial Reporting Standards (IFRS) represents a significant change to the ways companies will have to account and report on their value and performance. Roger Mills reviews the standard with a focus on practice. In doing so he gives companies guidelines on how to account for value. He concludes by offering both listed and non-listed companies practical advice on how to embrace the standard.
Broadening the Scope of Branding
Authors: Foreman Susan
Published: May 2017

Research into brand equity and the role of branding in diverse sections demonstrates its central importance – a finding confirmed in a recent poll of top managers who believe branding to be more significant now than ever before. Fascinating new approaches to describing brand value have been developed: some approach the brand as though it were a ‘share’ of the customer's mind; others consider branding in the industrial context – even industrial purchases are not immune to ‘something as fuzzy and irrational as a brand’.
Broadening the Scope of Branding
Authors: Foreman Susan
Published: May 2017

Research into brand equity and the role of branding in diverse sections demonstrates its central importance — a finding confirmed in a recent poll of top managers who believe branding to be more significant now than ever before. Fascinating new approaches to describing brand value have been developed: some approach the brand as though it were a ‘share’ of the customer's mind; others consider branding in the industrial context — even industrial purchases are not immune to ‘something as fuzzy and irrational as a brand’.
Corporate Failure
Authors: Turner Ian
Published: May 2017

What are the causes of corporate failure, and can they be avoided? Numerous studies reveal the alarmingly high failure rate of business initiatives, and corporate survival rates have recently declined across the major European economies. This article examines the range of explanations for failure, before considering whether failure can sometimes even be ‘good’.
Rationality, Foolishness and Adaptive Intelligence
Authors: Turner Ian
Published: May 2017

This article explores recent changes in thinking about innovation by considering the recent work of two key thinkers: James March and Gary Hamel. James March examines innovative product development: according to March, most decision-making within organisations is premised on the notion that humans behave rationally; yet the objections to a purely rational model of behaviour are numerous and compelling. An alternative approach to the rationalist model of decision-making is one that is feedback based; yet here too adaptive mechanisms can be conservative, myopic and torn between a logic of exploration and one of exploitation. For March the solution lies in trying to contain the risks of innovation. Gary Hamel underscores the importance of innovation in management approaches against a narrow view of innovation as related to products: organisations, he believes, routinely underestimate or even ignore the competitive advantage that management process innovation can confer.
Sustainability, Regulation and Reverse Logistics
Authors: Mills Roger
Published: May 2017

It is no longer enough for a company in today's business climate to focus on profits and growth. Environmental and social issues also need to be considered as a priority. Perhaps surprisingly, working on sustainability can make sound entrepreneurial sense – it is not just an ethical issue. Nevertheless, the demands of the challenges sustainability issues raise should not be underestimated.
Nobody Knows Anything
Authors: Turner Ian
Published: May 2017

The wild unpredictability of success rates in the Hollywood film industry is in fact a model of the unpredictability of success in many other areas of business. Is there any one factor that creates success? What impact do efforts towards success have on the final outcome of any business or product?
Identifying Best Practices in Cost Management
Authors: Favato Giampiero , Mills Roger
Published: May 2017

Cost management practices have been under substantial criticism for their lack of efficiency and capacity for coping with a rapidly evolving environment. Cost management applications generally fit into three major categories: diagnostic, re-engineering, or integrated cost management systems. Which of these costing systems should be regarded as the current best practices in cost management?
I Don’t Make Objects, I Make Projects: Selling Things and Selling Selves in Contemporary Artmaking
Authors: Gerber Alison , Childress Clayton
Published: May 2017

What role do artists play in the valuation of their activities? Theoretical perspectives on art have assumed that such value is closely linked to the prices of art objects and have minimized the place of content providers in the creation and definition of value. Through analysis of the writings of American, Canadian, and Swedish artists from 1967 to 2015, we find that artists move discursively from an object-oriented market logic to a market logic based in the provision of services, promoting new ways of accounting for value as they do so. Our findings suggest new ways to look at extant literature: 1) dominant theories treat artists as either structurally or intentionally insulated from the pricing of their work, while we show how artists act to define the value of artistic practice; 2) we show how terminology may remain stable while underlying meanings and institutionalized strategies aimed toward the accomplishment of goals evolve, and argue for the analysis of discursive practices beyond the search for stability or change in the usage of key terms; and finally, 3) we argue that analysts should look beyond price when aiming to understand the valuation of artistic practice.
Shared Electronic Health Record Systems: Key Legal and Security Challenges
Authors: Christiansen Ellen K. , Skipenes Eva , Hausken Marie F. , Skeie Svein , Østbye Truls , Iversen Marjolein M.
Published: May 2017

Use of shared electronic health records opens a whole range of new possibilities for flexible and fruitful cooperation among health personnel in different health institutions, to the benefit of the patients. There are, however, unsolved legal and security challenges. The overall aim of this article is to highlight legal and security challenges that should be considered before using shared electronic cooperation platforms and health record systems to avoid legal and security “surprises” subsequent to the implementation. Practical lessons learned from the use of a web-based ulcer record system involving patients, community nurses, GPs, and hospital nurses and doctors in specialist health care are used to illustrate challenges we faced. Discussion of possible legal and security challenges is critical for successful implementation of shared electronic collaboration systems. Key challenges include (1) allocation of responsibility, (2) documentation routines, (3) and integrated or federated access control. We discuss and suggest how challenges of legal and security aspects can be handled. This discussion may be useful for both current and future users, as well as policy makers.
Intelligence in Postnormal Times
Authors: Serra Jordi , Sardar Ziauddin
Published: May 2017

Intelligence services are under an enormous pressure. They have to deal with unusual threats that exhibit unprecedented behavior and often provoke unexpected and disproportionate impacts. They are increasingly ill prepared to meet new and emerging challenges largely because traditional methods are becoming less and less reliable, especially against asymmetric threats. This paper presents a postnormal times (PNT) perspective on intelligence, and argues that intelligence services must do more to cope with radically new hazards without understanding the characteristics and nature of postnormal change. It is necessary to appreciate how contradictions and complexity lead to chaotic behavior in any given situation, and come to terms with evolving levels of uncertainty and ignorance. PNT requires us to rethink the basic axioms of intelligence strategies and tactics.
Remittances as diplomatic leverage?: The precedent for Trump’s threat to restrict remittances to Mexico
Authors: Germano Roy
Published: May 2017

As a presidential candidate, Donald J. Trump argued that he could compel Mexico to pay for a border wall by threatening to restrict the flow of remittances sent by Mexicans living in the United States. The proposal was largely dismissed by the press and the political establishment. American officials, however, have used threats to restrict remittances as leverage before. Some experts believe, in fact, that a threat from three House Republicans to restrict remittance flows to El Salvador changed the outcome of El Salvador’s 2004 presidential election in favor of the pro-trade, US-friendly candidate favored by the Bush administration. The objectives of this article are to demonstrate that Trump’s proposal to use remittances as leverage has precedent and to use survey data to attempt to evaluate the claim that a threat to restrict remittances influenced the outcome of the 2004 Salvadoran presidential election. Statistical tests suggest that remittance recipients were indeed more likely to vote for the Bush administration’s preferred candidate in the 2004 election; however, it does not appear that remittance recipients changed the outcome, nor is it clear from the available data whether the remittances threat or some other factor caused remittance recipients to vote differently than non-recipients.
The Syria Trojan Women: Rethinking the public with therapeutic theater
Authors: Ziter Edward Blaise
Published: May 2017

Therapeutic theater projects with Syrian refugees in Jordan and Lebanon work at the intersection of the public and the private, facilitating individual healings while also promoting new group identities. The playing space becomes an open discursive field in which varied understandings of the self become platforms for new understandings of the nation. In the process, these artists/refugees trouble the boundaries between the private and the public, potentially creating a new public sphere that is not only revolutionary in its critique of entrenched political power but in its reformulation of the idea of the public itself. This article examines one such project, The Syria Trojan Woman, directed by Omar Abu Saada. The article places this work in the context of Abu Saada’s work in applied theater in Syria prior to the uprising and within the larger context of Syrian political theater. Applied theater, an umbrella term designating performance valued as efficacious as well as aesthetic, has had a brief and difficult history in Syria because of its capacity to undermine the regulation of speech. In the case of The Syria Trojan Woman, this speech has traveled beyond the countries hosting refugees through the efforts of non-governmental organizations that bring additional fundraising and consciousness-raising objectives to the endeavor. Through international tours and the use of new media, local performances become international phenomenon, further complicating the idea of a revolutionary public sphere.
Current Diagnosis and Management of Cervical Spondylotic Myelopathy
Authors: Bakhsheshian Joshua , Mehta Vivek A. , Liu John C.
Published: May 2017

Study Design:

Review.

Objectives:

Cervical spondylotic myelopathy (CSM) is a major cause of disability, particular in elderly patients. Awareness and understanding of CSM is imperative to facilitate early diagnosis and management. This review article addresses CSM with regard to its epidemiology, anatomical considerations, pathophysiology, clinical manifestations, imaging characteristics, treatment approaches and outcomes, and the cost-effectiveness of surgical options.

Methods:

The authors performed an extensive review of the peer-reviewed literature addressing the aforementioned objectives.

Results:

The clinical presentation and natural history of CSM is variable, alternating between quiescent and insidious to stepwise decline or rapid neurological deterioration. For mild CSM, conservative options could be employed with careful observation. However, surgical intervention has shown to be superior for moderate to severe CSM. The success of operative or conservative management of CSM is multifactorial and high-quality studies are lacking. The optimal surgical approach is still under debate, and can vary depending on the number of levels involved, location of the pathology and baseline cervical sagittal alignment.

Conclusions:

Early recognition and treatment of CSM, before the onset of spinal cord damage, is essential for optimal outcomes. The goal of surgery is to decompress the cord with expansion of the spinal canal, while restoring cervical lordosis, and stabilizing when the risk of cervical kyphosis is high. Further high-quality randomized clinical studies with long-term follow up are still needed to further define the natural history and help predict the ideal surgical strategy.
Impact of Operation Time on 30-Day Complications After Adult Spinal Deformity Surgery
Authors: Phan Kevin , Kim Jun S. , Capua John Di , Lee Nathan J. , Kothari Parth , Dowdell James , Overley Samuel C. , Guzman Javier Z. , Cho Samuel K.
Published: May 2017

Study Design:

Retrospective analysis of prospectively collected data.

Objective:

There is a paucity of data on the effect of operative duration on postoperative complications during adult spinal deformity surgery (ASDS). The study attempts to explore and quantify the association between increased operation times and postoperative complications.

Methods:

A retrospective cohort analysis was performed on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2010 to 2014. Patients (≥18 years of age) from the NSQIP database undergoing ASDS were separated into cohorts based on quartiles of operation duration. Chi-square and multivariate logistic regression models were used to identify risk factors.

Results:

A total of 5338 patients met the inclusion criteria and were divided per quartiles based on operative duration in minutes (154, 235, 346, and 1156 minutes). Multivariate logistic regressions revealed that in comparison to the lowest quartile of operative duration, the highest quartile group was associated significantly with length of stay ≥5 days (odds ratio [OR] = 5.85), any complication (OR = 9.88), wound complication (OR = 5.95), pulmonary complication (OR = 2.85, P = .001), venous thromboembolism (OR = 12.37), intra-/postoperative transfusion (OR = 12.77), sepsis (OR = 5.27), reoperations (OR = 1.48), and unplanned readmissions (OR = 1.29). The odds ratio was higher when comparing a higher quartile group with the reference group across all associations. P < .001 unless otherwise noted.

Conclusion:

ASDS operation time is associated with multiple postoperative complications, including, but not limited to, wound and pulmonary complications, venous thromboembolism, postoperative transfusion, length of stay ≥5 days, sepsis, reoperation, and unplanned readmission.
Time of Vote Choice in India
Authors: Sardesai Shreyas , Mishra Jyoti
Published: May 2017

This piece analyzes the subject Time of Vote Choice in India, a hitherto under-researched aspect of voting behaviour in the country. Using longitudinal data from National Election Studies conducted by Lokniti between 1996 and 2014, it shows that voting intentions of India’s voters are increasingly crystallizing before the start of the campaign period of an election. On the other hand, the proportion of voters postponing their vote choice to after the start of a campaign has declined over the last two decades. This declining trend is unique to India as most Western democracies have registered an overtime increase in campaign-period decision-making. While Indian voters who are less political, less partisan and less exposed to media are more likely to be late deciders than early ones, nevertheless, we also find that late deciders—both campaign-period and last-minute—have gradually become more politically sophisticated and attentive over the years. In this respect, our findings validate both the traditional floating voter theory of the Columbia School and some of the newer studies that have countered it.
Book Review: Hilal Ahmed, Muslim Political Discourse in Postcolonial India: Monuments, Memory, Contestation
Authors: Jaffrelot Christophe
Published: May 2017

Hilal Ahmed, Muslim Political Discourse in Postcolonial India: Monuments, Memory, Contestation. Delhi: Routledge. 2014. 328 pages. ₹ 850.
Book Review: Tariq Thachil, Elite Parties, Poor Voters: How Social Services Win Votes in India
Authors: Attri Vibha
Published: May 2017

Tariq Thachil, Elite Parties, Poor Voters: How Social Services Win Votes in India. Cambridge: Cambridge University Press (Studies in Comparative Politics Series). 2016. 331 pages. ₹795.
Book Review: Sunil Khilnani, Vikram Raghavan and Arun K. Thiruvengadam (eds), Comparative Constitutionalism in South Asia, Maneesha Tikekar (ed.), Constitutionalism and Democracy in South Asia; Political Developments in India’s Neighbourhood and Mark Tushent and Madhav Khosla (eds), Unstable Constitutionalism: Law and Politics in South Asia
Authors: Dhingra Alisha
Published: May 2017

Sunil Khilnani, Vikram Raghavan and Arun K. Thiruvengadam (eds), Comparative Constitutionalism in South Asia. New Delhi: Oxford University Press. 2013. 401 pages. ₹ 950.

Maneesha Tikekar (ed.), Constitutionalism and Democracy in South Asia; Political Developments in India’s Neighbourhood. New Delhi: Oxford University Press. 2014. 181 pages. ₹ 675.

Mark Tushent and Madhav Khosla (eds), Unstable Constitutionalism: Law and Politics in South Asia. New York: Cambridge University Press. 2015. 403 pages. US$ 35.99.
Book Review: Paula Banerjee, Anasua Basu Ray Chaudhury and Atig Ghosh (eds), The State of Being Stateless: An Account of South Asia
Authors: Sriramachandran Ravi
Published: May 2017

Paula Banerjee, Anasua Basu Ray Chaudhury and Atig Ghosh (eds), The State of Being Stateless: An Account of South Asia. Hyderabad: Orient BlackSwan. 2016. 300 pages. ₹ 675.
Youth Agricultural Land Access Dimensions and Emerging Challenges Under the Customary Tenure System in Ghana
Authors: Kidido Joseph Kwaku , Bugri John Tiah , Kasanga Raphael Kasim
Published: May 2017

The youth constitute an important human capital for the socio-economic growth and development of Ghana. As an agrarian economy, land remains a key resource in national economic development. Consequently, youth access to agricultural land is crucial in harnessing their potential for increased agricultural production. This study examines youth access to agricultural land dimensions under the customary system in Ghana. Using Techiman area as a case study, the study employed multiple sampling techniques to select the study communities and the respondents. In all, 455 youth and 23 elder respondents were covered. The results revealed that the youth have limited access to land for agricultural purpose on permanent basis. Land access mechanisms which convey temporary and limited rights such as licence and rentals were more popular among the youth respondents. This undermines their ability to make long-term investments and participate in cash crop cultivation. The study recommends a targeted youth agricultural land policy by government that will leverage the potential of the youth for increased agricultural production in the country.
New Faces of HIV Infection: Age, Race, and Timing of Entry into HIV Care in the Southeastern United States
Authors: Rebeiro Peter Francis , Ivey Kelsey Sunderland , Craig Kaylin Smith , Hulgan Todd , Huaman Moises Arturo , Nash Robertson , Raffanti Stephen , Equakun Kehinde Amen , Person Anna Kristine
Published: May 2017

Among younger men who have sex with men (MSM), the incidence of HIV is rising nationally. Of the 281 persons who entered into care at a large HIV clinic in the southeastern United States in 2010 to 2012, 78 (27.8%) were <25 years old at the time of diagnosis. Those in the younger group were more likely than those aged ≥25 to be black (59.0% versus 37.4%), MSM (78.2% versus 55.2%), and to have a longer median time from diagnosis to entry into care (71 versus 53 days; P < .05 each). In adjusted survival analysis, persons of black race were less likely to enter care after diagnosis than those of nonblack race (hazard ratio = 0.75, P = .02). Young MSM represent an important target population for prevention and HIV testing interventions, and there is a need to shorten the time from diagnosis to linkage to care, particularly in persons aged <25 and of black race.
Association of HIV/AIDS Clinician Warm Line Utilization with Diagnosis and Management of Antiretroviral Treatment Failure in Mozambique: A Retrospective Analysis of Program Data
Authors: Ruano Camps Maria , Brentlinger Paula E. , Augusto Gerito , Nguimfack Alexandre , Mudender Florindo
Published: May 2017

In accordance with global HIV/AIDS goals, Mozambique is attempting to improve management of antiretroviral treatment failure (TF). We sought to determine whether the utilization of a national HIV/AIDS clinician telephone consultation service increased recognition and reporting of TF. In a retrospective analysis of routinely collected program data from telephone consultation logs and Mozambique’s national registry of second-line antiretroviral requests, we used linear mixed methods to describe the association between TF-related telephone consultations and submission of second-line requests, which required documentation of the TF diagnosis. The unit of analysis was the health facility. Available data included 1417 consultations (390 [27.5%] TF related) and 2662 second-line requests from 1011 health units (2015-2016 data). In multivariable analyses, each TF-related consultation was associated with an increase of 0.61 (95% confidence interval 0.15 to 1.06) second-line requests. In this setting, TF-related telephone consultation was positively and significantly associated with diagnosis and reporting of antiretroviral TF.
The Role of the Peripheral Passive Rotation Stabilizers of the Knee With Intact Collateral and Cruciate Ligaments: A Biomechanical Study
Authors: Vap Alexander R. , Schon Jason M. , Moatshe Gilbert , Cruz Raphael S. , Brady Alex W. , Dornan Grant J. , Turnbull Travis Lee , LaPrade Robert F.
Published: May 2017

Background:

A subset of patients have clinical internal and/or external knee rotational instability despite no apparent injury to the cruciate or collateral ligaments.

Purpose/Hypothesis:

The purpose of this study was to assess the effect of sequentially cutting the posterolateral, anterolateral, posteromedial, and anteromedial structures of the knee on rotational stability in the setting of intact cruciate and collateral ligaments. It was hypothesized that cutting of the iliotibial band (ITB), anterolateral ligament and lateral capsule (ALL/LC), posterior oblique ligament (POL), and posteromedial capsule (PMC) would significantly increase internal rotation, while sectioning of the anteromedial capsule (AMC) and the popliteus tendon and popliteofibular ligament (PLT/PFL) would lead to a significant increase in external knee rotation.

Study Design:

Controlled laboratory study.

Methods:

Ten pairs (N = 20) of cadaveric knees were assigned to 2 sequential cutting groups (group 1: posterolateral-to-posteromedial [PL → PM] and group 2: posteromedial-to-posterolateral [PM → PL]). Specimens were subjected to applied 5-N·m internal and external rotation torques at knee flexion angles of 0°, 30°, 60°, and 90° while intact and after each cut state. Rotational changes were measured and compared with the intact and previous cut states.

Results:

Sectioning of the ITB significantly increased internal rotation at 60° and 90° by 5.4° and 6.2° in group 1 (PL → PM) and 3.5° and 3.8° in group 2 (PM → PL). PLT/PFL complex sectioning significantly increased external rotation at 60° and 90° by 2.7° and 2.9° in group 1 (PL → PM). At 60° and 90° in group 2 (PM → PL), ALL/LC sectioning produced significant increases in internal rotation of 3.1° and 3.5°, respectively. In group 2 (PM → PL), POL sectioning produced a significant increase in internal rotation of 2.0° at 0°. AMC sectioning significantly increased external rotation at 30° to 90° of flexion with a magnitude of change of <1° in both groups 1 (PL → PM) and 2 (PM → PL).

Conclusion:

Collectively, the anterolateral corner structures provided primary internal rotation control of the knee from 60° to 90° of knee flexion in knees with intact cruciate and collateral ligaments. The ITB was the most significant primary stabilizer of internal rotation. The POL had a primary role for internal rotational stability at full extension. The PLT/PFL complex was a primary stabilizer for external rotation of the knee at 60° and 90°.

Clinical Relevance:

This study delineates the primary and secondary roles of the ITB, ALL/LC, POL, and PLT/PFL to rotatory stability of the knee and provides new information to understand knee rotational instabilities.
Radiographic Diagnosis of Pincer-Type Femoroacetabular Impingement: A Systematic Review
Authors: Rhee Chanseok , Le Francois Tina , Byrd J. W. Thomas , Glazebrook Mark , Wong Ivan
Published: May 2017

Background:

Femoroacetabular impingement (FAI) is a well-recognized condition that causes hip pain and can lead to early osteoarthritis if not managed properly. With the increasing awareness and efficacy of operative treatments for pincer-type FAI, there is a need for consensus on the standardized radiographic diagnosis.

Purpose:

To perform a systematic review of the evidence regarding imaging modalities and radiographic signs for diagnosing pincer-type FAI.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A literature review was performed in 2016 using the Cochrane, PubMed, and Embase search engines. All articles focusing on a radiographic diagnosis of pincer-type FAI were reviewed. Each of the included 44 articles was assigned the appropriate level of evidence, and the particular radiographic marker and/or type of imaging were also summarized.

Results:

There were 44 studies included in the final review. Most of the articles were level 4 evidence (26 articles), and there were 12 level 3 and 6 level 2 articles. The crossover sign was the most commonly used radiographic sign (27/44) followed by the lateral center-edge angle (22/44). Anteroposterior (AP) pelvis plain radiographs were the most commonly used imaging modality (33 studies). Poor-quality evidence exists in support of most currently used radiographic markers, including the crossover sign, lateral center-edge angle, posterior wall sign, ischial spine sign, coxa profunda, acetabular protrusion, and acetabular index. There is poor-quality conflicting evidence regarding the use of the herniation pit to diagnose pincer-type FAI. Some novel measurements, such as β-angle, acetabular roof ratio, and acetabular retroversion index, have been proposed, but they also lack support from the literature.

Conclusion:

No strong evidence exists to support a single best set of current radiographic markers for the diagnosis of pincer-type FAI, largely due to the lack of better quality trials (levels 1 and 2) that compare conventional radiographic findings with the gold standard, which is the intraoperative findings. More sophisticated imaging modalities such as computed tomography and magnetic resonance arthrography are often needed to diagnose pincer-type FAI, and these investigations are relatively accurate in assessing labral pathology or cartilage damage.
Soft Tissue Envelope Preserving Technique for Computer Navigated Total Knee Arthroplasty
Authors: Clark Gavin , Mooney Luke
Published: May 2017

Objectives:

Current techniques in Total Knee Arthroplasty(TKA) are utilitarian in that all patients are recommended to have the same alignment of neutral mechanical axis. It has been well established that the population has a varied natural alignment with less than 20% of patients naturally neutral. The ability to predictably individualise alignment for patients is hypothesised to result in greater patient satisfaction. This technique aims to modify mechanical axis technique to consider an individual’s soft tissue constraints.

Methods:

Soft Tissue Envelope Preserving (STEP) is an operative technique for performing TKA that utilises the soft tissue data obtained intra-operatively from computer navigation registration to determine the optimal alignment to provide balanced positioning of implants without the need for soft tissue releases. Hence balance is achieved through bone cuts rather than altering the patient’s soft tissue balance. The technique will be described in detail.

Results:

The last 100 patients performed with complete data sets including navigation files and both pre-op and one year post operative outcome measures were reviewed. The spread of overall alignments and bony resections have been compiled with no outliers outside 5 degrees of neutral. The clinical results were comparable with other series and patient satisfaction of greater than 90% was reported. There were no MCL or LCL releases performed. Ilio-tibial band partial releases were the only reported soft tissue releases made.

Conclusions:

This technique is a safe and effective method of performing TKA with good short term outcomes. It minimises the use of soft tissue releases by utilising the patient’s own soft tissue envelope to balance the knee whilst maintaining the basic principles of a measured resection mechanical axis technique. It has resulted in excellent patient satisfaction in the short term.
Accuracy of Manual Surgeon-Defined Assessment of Soft Tissue Balance in TKA In Comparison to Sensor-Guided Measures and its Effect on Final Balance
Authors: MacDessi Samuel , Gharaibeh Monther
Published: May 2017

Objectives:

Present literature supports the importance of final alignment and soft tissue balance in total knee arthroplasty (TKA) on implant survivorship and clinical outcomes. Current soft tissue balance techniques mostly depend on subjective static measures that don’t allow for quantitative determination of ligament tension. Sensor guided technique (Verasense, Orthosensor) allows demonstration of the magnitude and location of load in a dynamic way providing quantitative data about knee balance. The aim of this study is to test the accuracy of the surgeon’s manual assessment in judging knee balance in comparison to Verasense. We also aimed to determine whether Verasense can assist in achieving soft tissue balance from the unbalanced state.

Methods:

58 patients were enrolled in this prospective cohort study. The level of agreement between SDA and Verasense at 10, 45, 90 degrees was recorded. Initial trial pressures and final pressures after release or re-cut were recorded and compared. Final pressure measurements were then documented to assess whether appropriate knee balance (differential compartmental pressure of 15 lb/inch on 2 or more angular positions) had been achieved.

Results:

The mean age of the cohort was 67.5 years with deformities ranging from -16 degrees of varus to +20 degrees of valgus (mean -1.26 degrees varus). The capacity for the surgeon to manually identify an unbalanced knee was low with a test sensitivity of 33.3%. Manual test specificity to define a balanced knee was better with a specificity of 77.3%. The manual test had a positive predicitive value of 59.2% and a negative predictive value of 54%. There were 46.5% (27 of 58) of cases where the Verasense lead to a different surgical plan to that initially determined by the manual assessment. In 23 cases, either ligament release or tibial bone recut was performed. In the remaining 4 cases, the Verasense prevented a ligament release being performed. 95% of cases achieved a balanced state within 15lb/inch of pressure between compartments, with 100% balanced within 25 lb/inch.

Conclusion:

Manual surgeon assessment of soft tissue balance is a poor predictor of unbalanced knees. Verasense has the capacity to subsequently balance the knee within an acceptable pressure range as defined by prior studies. Further analysis to determine the impact on patient outcomes and implant survivorship is warranted.
Patella Eversion in Knee Arthroplasty: Does it lead to an adverse outcome?
Authors: Reid Michael , Booth Grant , Khan Riaz JK , Janes Greg
Published: May 2017

Objectives:

Proponents of minimally invasive knee replacements argue that retracting rather than everting the patella results in quicker postoperative recovery and improved function compared to the standard approach. We aimed to investigate this in a group of patients undergoing knee arthroplasty using a standard medial parapatellar approach.

Methods:

In a prospective randomized double-blinded study sixty-eight patients undergoing total knee arthroplasty through a standard medial parapatellar approach were assigned to either retraction or eversion of the patella. An independent observer assessed the flexion and secondary outcome measures of Oxford knee score, the SF12 score, visual analog pain scores, range of motion data and radiographs preoperatively, at three months and at one-year post surgery.

Results:

Early (3 month) follow-up showed no significant difference between eversion and subluxation in flexion (mean and 95%CI, 101°± 5.37 vs 102°±4.14) Oxford knee scores (25±3 vs 27±2.69), SF12 or visual analog pain scores (1.9±0.54 vs 1.1±0.44). A statistically significant improvement in extension was found (-3.9°±1.12 vs 2.0°±0.91 (p=0.034)) but this was not thought to be clinically significant. There was no difference in any outcomes at one year. There was a significant difference in implant malpositioning in the subluxation group with increased percentage lateral tibial overhang (0.45±0.39 vs 1.84±0.82 (p=0.005)) but this did not correlate with functional outcome. There was no statistical difference in alignment between the two groups (178.29°±0.84 vs 178.18°±0.78). There was no difference between the two groups in Insall-Salvati Ratio (1.15±0.06 vs 1.12±0.06) although there was a correlation to a reduction in the ratio and functional outcome. There were two partial divisions of the patella tendon in the retraction group, but no patella related complications in the eversion group.

Conclusion:

Retracting rather than everting the patella during total knee arthroplasty results in no significant clinical benefit in the early to medium term. There is no increase in patella tendon shortening as a result of eversion rather than subluxation.
The Seasonal Variation of TKR Infection Rates
Authors: Parkinson Ben , Armit Drew , Reid Michael , Lorimer Michelle , Harris Ian
Published: May 2017

Introduction:

A seasonal variation in the incidence of surgical site infections has been described following a number of common surgical procedures. However in the setting of elective Total Knee Replacement (TKR), the role of environmental factors is an area of research that is currently lacking from the literature. Data recently presented from our institution demonstrates a possible trend toward higher infection rates during periods of increased temperature and humidity. The aim of this study was to investigate if seasonal and geographical factors influence the rate of TKR infection within Australia.

Methods:

Data from the AOA National Joint Registry for all primary TKRs performed within the last 5 years was analysed to determine the revision rates for early (<12 months) post-operative infection. The infection rates for tropical regions (Darwin, Cairns, Townsville, Mackay) were compared to the remainder of the country. A month-by-month analysis was performed to determine if there was a seasonal variation within the 2 study groups.

Results:

During the study period a total of 207,540 primary TKRs were performed (6,514 tropical vs 201,026 non-tropical regions). Overall, the rate of revision for infection was significantly higher for the tropical regions of Australia (0.80% vs 0.39%). In non-tropical regions, there was no observed seasonal variation of infection rates. In tropical regions, there was a clear seasonal variation found, with the winter months being associated with a significantly lower rate of infection than the remainder of the year (0.37% vs 0.94%). The infection rates were not significantly different between tropical (0.37%) and non- tropical (0.38%) regions during the winter period.

Conclusion:

To the best of our knowledge, this is the first study to investigate and demonstrate a significant influence from seasonal variation on primary TKR infection rates. This phenomenon is evident only within tropical regions, with the periods of warmer and humid weather resulting in a significantly increased risk of primary TKR infection. These findings require further investigation and research.
Return to sport outcomes in the younger patient with anterior cruciate ligament reconstruction
Authors: Whitehead TS , Feller JA , Webster KE
Published: May 2017

Objective:

Anterior cruciate ligament (ACL) reconstruction is generally regarded as a successful procedure, however only 65% of patients return to their pre-injury sport. While return to sport rates are likely higher in younger patients, there is a paucity of data on this topic. The purpose of this study was to investigate a range of return to sport outcomes in younger athletes who had undergone ACL reconstruction surgery.

Methods:

This was a cross-sectional study design. A group of 140 young patients (<20 years at surgery) who had one ACL reconstruction and no subsequent ACL injuries were surveyed regarding details of their sport participation at an average follow up of 5 years (range 3-7).

Results:

Overall, 76% of the young patient group returned to the same pre-injury sport. Return rates were higher for males than females (81% vs. 71% respectively, p>0.05). Of those who returned to their sport, 65% reported that they could perform as well as before the ACL injury and 66% were still currently playing in their respective sport. Young athletes who never returned to sport cited fear of a new injury (37%) or study/work commitments (30%) as the primary reasons. For those who had successfully returned to their pre-injury sport but subsequently stopped playing, the most common reason was study/work commitments (53%). At follow-up 48% of female patients were still participating in Level I sports as were 54% of males.

Conclusions:

A high percentage of younger patients return to their pre-injury sport following ACL reconstruction surgery. For this group who have not sustained a second ACL injury, the majority continue to play and are satisfied with their performance.
Histological Analysis of the Tibial Anterior Cruciate Ligament Insertion
Authors: Siebold Rainer , Oka Shinya , Traut Ulrike , Schuhmacher Peter , Kirsch Joachim
Published: May 2017

Objective:

To describe the morphology of the tibial ACL insertion by histological assessment in the sagittal plane.

Methods:

For histology the native (undissected) tibial ACL insertion of 6 fresh-frozen cadaveric knees was cut into 4 sagittal sections parallel to the long axis of the medial tibial spine. The slices were stained with hematoxylin and eosin, Safranin O and Russell-Movat pentachrome. All slices were digitalized and analyzed at a magnification of ×20.

Results:

From medial to lateral the anterior-posterior lengths of the ACL insertion were an average of 10.2, 9.3, 7.6 and 5.8 mm. The anterior margin of the tibial ACL insertion raised from an anterior ridge. The most medial ACL fibers rose along with a peak of the anterior part of the medial tibial spine in which the direct insertion was adjacent to the articular cartilage. Parts of the bony insertions of the anterior and posterior horns of the lateral meniscus were in close contact to the lateral ACL insertion. A small fat pad was located just posterior to the tibial ACL insertion. There were no central or posterolateral inserting ACL fibers in the area intercondylaris anterior.

Conclusion:

The functional intraligamentous midsubstance ACL fibers arose from the most posterior part of its bony tibial insertion in a flat and “C-shape” way. The anterior border of this functional ACL started from a bony ‘anterior ridge’ and the medial border was along with a peak of the medial tibial spine.
HAMSTRING MORPHOLOGY AND STRENGTH REMAIN ALTERED 2 YEARS FOLLOWING A HAMSTRING GRAFT IN ACL RECONSTRUCTION
Authors: Vertullo Christopher J. , Konrath Jason M. , Kennedy Benjamin , Bush Hamish , Barrett Rodney S. , Lloyd David G.
Published: May 2017

Background:

The hamstring graft used in anterior cruciate ligament (ACL) reconstruction has been shown to lead to changes to the semitendinosus and gracilis musculature. This study further evaluated the effect of the surgery on hamstring muscle morphology and knee muscle strength at 2 years post-surgery.

Hypotheses:

(1) Loss of donor muscle size would significantly correlate with knee muscle strength deficits (2) Loss of donor muscle size would be greater for muscles that do not experience tendon regeneration, and (3) Morphological adaptations would also be evident in non-donor knee muscles.

Study Design:

Cross sectional evaluation.

Methods:

20 participants (14 male, 6 female, 29 ± 7 years, 82 ± 15 kg) that had undergone a hamstring graft in ACL reconstruction at least two years previously, underwent bilateral MRI and subsequent strength testing. Muscle and tendon volumes, peak CSA’s and lengths were determined for 12 muscles and 6 functional muscle groups of the surgical and contralateral limbs. Peak isokinetic concentric strength was measured in knee flexion/extension and internal/external tibial rotation.

Results:

Only 50% of the patients regenerated both the semitendinosus and gracilis tendons. The regenerated tendons were longer with larger volume and CSA compared to the contralateral side. Deficits in semitendinosus and gracilis muscle size were greater for tendons that did not regenerate. In addition, combined hamstrings (semitendinosus, semimembranosus, biceps femoris) and combined medial knee muscles (semitendinosus, semimembranosus, gracilis, vastus medialis, medial gastrocnemius, sartorius) on the surgical side were reduced in volume by 12% and 10% respectively. A 7% larger volume was observed in the surgical leg for the biceps femoris and corresponded with a lower internal/external tibial rotation strength ratio. The difference in volume, peak CSA and length of the semitendinosus and gracilis correlated significantly with the deficit in knee flexion strength with Pearson correlations of 0.51, 0.57 and 0.61 respectively.

Conclusion:

The muscle-tendon properties of the semitendinosus and gracilis are substantially altered following harvesting, and these alterations may contribute to knee flexor weakness in the surgical limb. These deficits are more pronounced in tendons that do not regenerate and are only partially offset by compensatory hypertrophy of other hamstring muscles.

Clinical Relevance:

Surgeons should consider muscle retraction of the hamstring following tendon harvest in their choice of graft option for ACL reconstruction.
Arthroscopic assessment of patellofemoral tracking predicts patellar instability
Authors: Kejriwal Ritwik , Annear Peter
Published: May 2017

Objectives:

Surgical management of patellar instability includes proximal realignment procedure such as MPFL reconstruction. The decision to add a distal realignment procedure of tibial tubercle transfer is based on severity of patellar instability judged on either TTTG distance or arthroscopic patellofemoral tracking. We set out to validate our use of arthroscopic patellofemoral tracking for patellar instability management algorithm by analyzing its reproducibility and whether it correlates with patellar instability.

Methods:

A prospective observational study was carried out at Perth Orthopaedic and Sports Medicine Centre. Patient clinical presentations were divided into three groups - patellofemoral instability, patellofemoral pain, and no patellofemoral symptoms. Standard technique included low flow arthroscopy with single anterolateral viewing portal. Height of the fluid bag and presence of a knee holder was recorded. Knee flexion angle where patella first centrally engages in the trochlear groove was defined as Patellofemoral Congruent Angle (PCA). PCA was estimated by the primary surgeon and the angle was confirmed using a sterile goniometer. A second surgeon, blinded to the initial assessment, then repeated the measurements. Surgeon estimation error, interobserver reliability, and correlation with clinical presentation was analysed.

Results:

57 knees were assessed for interobserver reliability. Intra-class correlation was 0.994 between surgeon’s estimate and goniometer reading. Intra-class correlation was 0.992 between the two surgeon’s readings suggesting a very high correlation. 157 patients had their PCA recorded and compared with their diagnosis. Mean PCA was 40 degrees in normal patients, and 118 degrees in patellar instability (p-value <0.001).

Conclusion:

Arthroscopic assessment of patellofemoral tracking is reproducible and correlates with patellar instability. A cut-off value of 40 degrees is recommended to differentiate normal tracking from abnormal.