Use of Bone Health Evaluation in Orthopedic Surgery: 2019 ISCD Official Position.

This position development conference (PDC) Task Force examined the assessment of bone status in orthopedic surgery patients. Key questions included which orthopedic surgery patients should be evaluated for poor bone health prior to surgery and which subsets of patients are at high risk for poor bone health and adverse outcomes. Second, the reliability and validity of using bone densitometry techniques and measurement of specific geometries around the hip and knee before and after arthroplasty was determined. Finally, the use of computed tomography (CT) attenuation coefficients (Hounsfield units) to estimate bone quality at anatomic locations where orthopedic surgery is performed including femur, tibia, shoulder, wrist, and ankle were reviewed. The literature review identified 665 articles of which 198 met inclusion exclusion criteria and were selected based on reporting of methodology, reliability, or validity results. We recommend that the orthopedic surgeon be aware of established ISCD guidelines for determining who should have additional screening for osteoporosis. Patients with inflammatory arthritis, chronic corticosteroid use, chronic renal disease, and those with history of fracture after age 50 are at high risk of osteoporosis and adverse events from surgery and should have dual energy X-ray absorptiometry (DXA) screening before surgery. In addition to standard DXA, bone mineral density (BMD) measurement along the femur and proximal tibia is reliable and valid around implants and can provide valuable information regarding bone remodeling and identification of loosening. Attention to positioning, selection of regions of interest, and use of special techniques and software is required. Plain radiographs and CT provide simple, reliable methods to classify the shape of the proximal femur and to predict osteoporosis; these include the Dorr Classification, Cortical Index, and critical thickness. Correlation of these indices to central BMD is moderate to good. Many patients undergoing orthopedic surgery have had preoperative CT which can be utilized to assess regional quality of bone. The simplest method available on most picture archiving and communications systems is to simply measure a regions of interest and determine the mean Hounsfield units. This method has excellent reliability throughout the skeleton and has moderate correlation to DXA based on BMD. The prediction of outcome and correlation to mechanical strength of fixation of a screw or implant is unknown.

Assistive technology products: a position paper from the first global research, innovation, and education on assistive technology (GREAT) summit.

This paper is based on work from the Global Research, Innovation, and Education on Assistive Technology (GREAT) Summit that was coordinated by WHO's Global Cooperation on Assistive Technology (GATE). The purpose of this paper is to describe the needs and opportunities embedded in the assistive product lifecycle as well as issues relating to the various stages of assistive product mobilization worldwide. The paper discusses assistive technology product terminology and the dangers of focusing on products outside the context and rolling out products without a plan. Additionally, the paper reviews concepts and issues around technology transfer, particularly in relation to meeting global needs and among countries with limited resources. Several opportunities are highlighted including technology advancement and the world nearing a state of readiness through a developing capacity of nations across the world to successfully adopt and support the assistive technology products and applications. The paper is optimistic about the future of assistive technology products reaching the people that can use it the most and the excitement across large and small nations in increasing their own capacities for implementing assistive technology. This is expressed as hope in future students as they innovate and in modern engineering that will enable assistive technology to pervade all corners of current and potential marketplaces. Importantly, the paper poses numerous topics where discussions are just superficially opened. The hope is that a set of sequels will follow to continue this critical dialog. Implications for Rehabilitation Successful assistive technology product interventions are complex and include much more than the simple selection of the right product. Assistive technology product use is highly context sensitive in terms of an individual user's environment. The development of assistive technology products is tricky as it must be contextually sensitive to the development environment and market as well. As a field we have much to study and develop around assistive technology product interventions from a global perspective.

Four Models to Guide AT Projects Intending Innovative Technology Development Outcomes.

Generating innovations - including Assistive Technology products or services - requires expertise in project planning and management. University faculty and small businesses ventures often lack such expertise for development and production tasks, yet governments allocate most funding to these sectors. They need help to achieve results. Four evidence-based models now exist to guide investigators intending to generate AT innovations in: 1) standards/guidelines; 2) tools/ instruments; 3) freeware or 4) commercial products.

Delivering beneficial impacts in Assistive Technology: Improving government's approach to innovation.

Society typically relies on the industrial sector to supply product and service innovations through the free market system. In some areas of free market failure deemed important to society - such as Assistive Technology - governments intervene by applying alternative innovation systems. This paper contends that governments consistently and inappropriately support an exploratory grant approach led by academia which generates knowledge in conceptual and prototype states, and instead should shift to a procurement contract approach led by industry which designs, tests and deploys commercial products and services.

Comparing three knowledge communication strategies - Diffusion, Dissemination and Translation - through randomized controlled studies.

This paper describes a series of three randomized controlled case studies comparing the effectiveness of three strategies for communicating new research-based knowledge (Diffusion, Dissemination, Translation), to different Assistive Technology (AT) stakeholder groups. Pre and post intervention measures for level of knowledge use (unaware, aware, interested, using) via the LOKUS instrument, assessed the relative effectiveness of the three strategies. The latter two approaches were both more effective than diffusion but also equally effective. The results question the value added by tailoring research findings to specific audiences, and instead supports the critical yet neglected role for relevance in determining knowledge use by stakeholders.

Level Of Knowledge Use Survey (LOKUS): A validated instrument for tracking knowledge uptake and use.

Researchers working in fields intending to generate beneficial socio-economic impacts are increasingly challenged to demonstrate evidence that the findings from their studies have value to audiences beyond the peer academic community. These diverse and diffuse target audiences may include clinicians, consumers, manufacturers and information brokers. This paper summarizes a project that designed, constructed and validated a web-based instrument for collecting and analyzing self-reported data on knowledge use. The Level Of Knowledge Use Survey instrument is valid and reliable for measuring uptake of new knowledge and for tracking changes in level of knowledge use over time.

Development of a measure of knowledge use by stakeholders in rehabilitation technology.

OBJECTIVES: Uptake of new knowledge by diverse and diffuse stakeholders of health-care technology innovations has been a persistent challenge, as has been measurement of this uptake. This article describes the development of the Level of Knowledge Use Survey instrument, a web-based measure of self-reported knowledge use. METHODS: The Level of Knowledge Use Survey instrument was developed in the context of assessing effectiveness of knowledge communication strategies in rehabilitation technology. It was validated on samples representing five stakeholder types: researchers, manufacturers, clinician-practitioners, knowledge brokers, and consumers. Its structure is broadly based on Rogers' stages of innovation adoption. Its item generation was initially guided by Hall et al's Levels of Use framework. Item selection was based on content validity indices computed from expert ratings (n 1 = 4; n 2 = 3). Five representative stakeholders established usability of the web version. The version included 47 items (content validity index for individual items >0.78; content validity index for a scale or set of items >0.90) in self-reporting format. Psychometrics were then established for the version. RESULTS: Analyses of data from small (n = 69) and large (n = 215) samples using the Level of Knowledge Use Survey instrument suggested a conceptual model of four levels of knowledge use-Non-awareness, Awareness, Interest, and Use. The levels covered eight dimensions and six user action categories. The sequential nature of levels was inconclusive due to low cell frequencies. The Level of Knowledge Use Survey instrument showed adequate content validity (≈ 0.88; n = 3) and excellent test-retest reliability (1.0; n = 69). It also demonstrated good construct validity (n = 215) for differentiating among new knowledge outputs (p < 0.001) and among stakeholder types (0.001 < p ≤ 0.013). It showed strong responsiveness to change between baseline and follow-up testing (0.001 < p ≤ 0.002; n = 215). CONCLUSION: The Level of Knowledge Use Survey instrument is valid and reliable for measuring uptake of innovations across diffuse stakeholders of rehabilitation technologies and therefore also for tracking changes in knowledge use.

Need to Knowledge (NtK) Model: an evidence-based framework for generating technological innovations with socio-economic impacts.

BACKGROUND: Traditional government policies suggest that upstream investment in scientific research is necessary and sufficient to generate technological innovations. The expected downstream beneficial socio-economic impacts are presumed to occur through non-government market mechanisms. However, there is little quantitative evidence for such a direct and formulaic relationship between public investment at the input end and marketplace benefits at the impact end. Instead, the literature demonstrates that the technological innovation process involves a complex interaction between multiple sectors, methods, and stakeholders. DISCUSSION: The authors theorize that accomplishing the full process of technological innovation in a deliberate and systematic manner requires an operational-level model encompassing three underlying methods, each designed to generate knowledge outputs in different states: scientific research generates conceptual discoveries; engineering development generates prototype inventions; and industrial production generates commercial innovations. Given the critical roles of engineering and business, the entire innovation process should continuously consider the practical requirements and constraints of the commercial marketplace.The Need to Knowledge (NtK) Model encompasses the activities required to successfully generate innovations, along with associated strategies for effectively communicating knowledge outputs in all three states to the various stakeholders involved. It is intentionally grounded in evidence drawn from academic analysis to facilitate objective and quantitative scrutiny, and industry best practices to enable practical application. SUMMARY: The Need to Knowledge (NtK) Model offers a practical, market-oriented approach that avoids the gaps, constraints and inefficiencies inherent in undirected activities and disconnected sectors. The NtK Model is a means to realizing increased returns on public investments in those science and technology programs expressly intended to generate beneficial socio-economic impacts.

Modeling technology innovation: how science, engineering, and industry methods can combine to generate beneficial socioeconomic impacts.

BACKGROUND: Government-sponsored science, technology, and innovation (STI) programs support the socioeconomic aspects of public policies, in addition to expanding the knowledge base. For example, beneficial healthcare services and devices are expected to result from investments in research and development (R&D) programs, which assume a causal link to commercial innovation. Such programs are increasingly held accountable for evidence of impact-that is, innovative goods and services resulting from R&D activity. However, the absence of comprehensive models and metrics skews evidence gathering toward bibliometrics about research outputs (published discoveries), with less focus on transfer metrics about development outputs (patented prototypes) and almost none on econometrics related to production outputs (commercial innovations). This disparity is particularly problematic for the expressed intent of such programs, as most measurable socioeconomic benefits result from the last category of outputs. METHODS: This paper proposes a conceptual framework integrating all three knowledge-generating methods into a logic model, useful for planning, obtaining, and measuring the intended beneficial impacts through the implementation of knowledge in practice. Additionally, the integration of the Context-Input-Process-Product (CIPP) model of evaluation proactively builds relevance into STI policies and programs while sustaining rigor. RESULTS: The resulting logic model framework explicitly traces the progress of knowledge from inputs, following it through the three knowledge-generating processes and their respective knowledge outputs (discovery, invention, innovation), as it generates the intended socio-beneficial impacts. It is a hybrid model for generating technology-based innovations, where best practices in new product development merge with a widely accepted knowledge-translation approach. Given the emphasis on evidence-based practice in the medical and health fields and "bench to bedside" expectations for knowledge transfer, sponsors and grantees alike should find the model useful for planning, implementing, and evaluating innovation processes. CONCLUSIONS: High-cost/high-risk industries like healthcare require the market deployment of technology-based innovations to improve domestic society in a global economy. An appropriate balance of relevance and rigor in research, development, and production is crucial to optimize the return on public investment in such programs. The technology-innovation process needs a comprehensive operational model to effectively allocate public funds and thereby deliberately and systematically accomplish socioeconomic benefits.

Engaging national organizations for knowledge translation: comparative case studies in knowledge value mapping.

BACKGROUND: Government sponsors of research and development, along with their funded investigators, are increasingly tasked with demonstrating evidence of knowledge use by nontraditional audiences. This requires efforts to translate their findings for effective communication. For technology-related knowledge, these audiences include clinicians, consumers, manufacturers, public policy agencies, and knowledge brokers. One potentially efficient approach is to communicate research findings through relevant national organizations. However, this requires an understanding of how such organizations view and treat research knowledge, which can be determined through knowledge-value mapping. Do knowledge values differ between national organizations representing different audiences? Can a deeper understanding of knowledge values help sponsors, investigators, and organizations better communicate research findings to stakeholders? METHODS: A series of comparative case studies on knowledge-value mapping were derived through interviews with spokespersons for six national organizations. The semi-structured interviews followed a 10-item questionnaire to characterize different ways in which each organization engages with research-based knowledge. Each participating organization represents a particular stakeholder group, while all share a common interest in the research subject matter. RESULTS: Each national organization considers the value of the research knowledge in the context of their organization's mission and the interests of their members. All are interested in collaborating with researchers to share relevant findings, while they vary along the following dimensions of knowledge engagement: create, identify, translate, adapt, communicate, use, promote, absorptive capacity, and recommendations for facilitation. CONCLUSIONS: The principles of knowledge translation suggest that investigators can increase use by tailoring the format and context of their findings to the absorptive capacity of nonscholars. Greater absorption should result in higher levels of knowledge awareness, interest, and use, which can then be documented. National organizations and their members, in turn, can strive to optimize their absorptive capacities regarding the state of the sciences. This combination will ensure the highest possible return on public investment in research activities. This knowledge-value mapping study concludes that national organizations are appropriate channels for communicating research findings and for meeting statutory requirements and general expectations for generating and documenting knowledge use.

Translating three states of knowledge--discovery, invention, and innovation.

BACKGROUND: Knowledge Translation (KT) has historically focused on the proper use of knowledge in healthcare delivery. A knowledge base has been created through empirical research and resides in scholarly literature. Some knowledge is amenable to direct application by stakeholders who are engaged during or after the research process, as shown by the Knowledge to Action (KTA) model. Other knowledge requires multiple transformations before achieving utility for end users. For example, conceptual knowledge generated through science or engineering may become embodied as a technology-based invention through development methods. The invention may then be integrated within an innovative device or service through production methods. To what extent is KT relevant to these transformations? How might the KTA model accommodate these additional development and production activities while preserving the KT concepts? DISCUSSION: Stakeholders adopt and use knowledge that has perceived utility, such as a solution to a problem. Achieving a technology-based solution involves three methods that generate knowledge in three states, analogous to the three classic states of matter. Research activity generates discoveries that are intangible and highly malleable like a gas; development activity transforms discoveries into inventions that are moderately tangible yet still malleable like a liquid; and production activity transforms inventions into innovations that are tangible and immutable like a solid. The paper demonstrates how the KTA model can accommodate all three types of activity and address all three states of knowledge. Linking the three activities in one model also illustrates the importance of engaging the relevant stakeholders prior to initiating any knowledge-related activities. SUMMARY: Science and engineering focused on technology-based devices or services change the state of knowledge through three successive activities. Achieving knowledge implementation requires methods that accommodate these three activities and knowledge states. Accomplishing beneficial societal impacts from technology-based knowledge involves the successful progression through all three activities, and the effective communication of each successive knowledge state to the relevant stakeholders. The KTA model appears suitable for structuring and linking these processes.

Effect of WBC reduction and storage temperature on PLTs frozen with 6 percent DMSO for as long as 3 years.

BACKGROUND: PLTs frozen with 6 percent DMSO can be stored at -80 degrees C for 2 years, while those frozen with 5 percent DMSO at -150 degrees C can be stored for at least 3 years. The more rapid deterioration seen in PLTs frozen at -80 degrees C may be due to the presence of granulocytes. The effects of storage temperature and WBC reduction on PLTs frozen with DMSO and the breakage of the PVC plastic bags stored at -80 and -135 degrees C were assessed. STUDY DESIGN AND METHODS: Apheresed PLT-rich plasma (PRP) was either divided into two equal volumes where one volume was WBC-reduced and the other volume was not or filtered or not and then divided into two equal volumes. PLTs frozen with 6 percent DMSO were stored in PVC plastic bags at either -80 or -135 degrees C for as long as 3 years. RESULTS: After 2 years of storage at -80 degrees C, the PLTs exhibited satisfactory freeze-thaw-wash values regardless of whether or not they were WBC-reduced, but after 2 to 3 years of storage at -80 degrees C, the PLTs had significantly reduced freeze-thaw-wash values. Freeze-thaw-wash values were not reduced in PLTs stored at -135 degrees C for up to 3 years. CONCLUSIONS: WBC reduction did not improve freeze-thaw-wash recovery values in PLTs stored at -80 or -135 degrees C for up to 3 years, but reducing the storage temperature from -80 to -135 degrees C did. Breakage of PVC plastic bags stored at -135 degrees C was excessive.

Incidence of breakage of human RBCs frozen with 40-percent wt/vol glycerol using two different methods for storage at -80 degrees C.

BACKGROUND: We reported previously that the incidence of breakage was 34.2 percent when human RBCs were frozen with 40-percent wt/vol glycerol in polyolefin plastic bags stored in aluminum containers at -80 degrees C and subjected to transportation. When human RBCs were frozen with 40-percent wt/vol glycerol at -80 degrees C in PVC plastic bags placed in polyester plastic bags and stored in rigid corrugated cardboard boxes, transportation resulted in a 2.4-percent incidence of breakage. The present study was done to confirm this incidence of breakage. STUDY DESIGN AND METHODS: The Meryman- Hornblower freezing method was compared to the Naval Blood Research Laboratory (NBRL) method of freezing for incidence of bag breakage. Human RBCs frozen by the Meryman-Hornblower method with 40-percent wt/vol glycerol with supernatant glycerol and stored in polyolefin plastic bags in aluminum containers at -80 degrees C were stored at the NBRL from 1974 to 2002. With the NBRL method, human RBCs frozen at -80 degrees C without supernatant glycerol in the 800-mL PVC plastic primary bag inside a polyester plastic bag in a rigid corrugated cardboard box were stored at the NBRL from 1984 to 2002. RESULTS: The incidence of breakage for 532 units of RBCs that had been frozen by the Meryman- Hornblower method and stored in aluminum containers was 47.3 percent for nontransported units. RBCs that had been frozen by the NBRL method and stored in rigid corrugated cardboard boxes exhibited breakage of 2.4 percent for 2424 nontransported units and 6.7 percent for 633 transported units. DISCUSSION: The incidence of breakage was significantly lower for RBCs frozen by the NBRL method than for the RBCs frozen by the Meryman-Hornblower method.

Accomplishing technology transfer: case-based lessons of what works and what does not.

This paper presents lessons drawn from technology transfer case studies that address the persistent question: "What works, what does not, and why?" Each lesson highlights critical factors determining success or failure and is substantiated by case studies that exemplify the lesson. The case examples involve either the commercialization of prototype inventions (supply-push technology transfer) or the acquisition of desired technologies from other fields of application (demand-pull technology transfer). The cases present the chronology of events as they actually occurred, including supporting information from the other participants. Applying the lessons should help avoid common mistakes while increasing the likelihood of accomplishing the desired outcomes.