State Implementation of SNAP Waivers and Flexibilities During the COVID-19 Pandemic: Perspectives From State Agency Leaders.

OBJECTIVE: To describe state agencies' implementation of the Supplemental Nutrition Assistance Program (SNAP) during the first year of the coronavirus disease of 2019 (COVID-19) pandemic, barriers and facilitators to SNAP implementation, and recommendations to improve SNAP implementation. DESIGN: Qualitative methodology guided by Bullock's determinants of policy implementation framework using 7 semistructured, virtual focus groups in April 2021. SETTING: Twenty-six states representing all 7 US Department of Agriculture Food and Nutrition Service regions. PARTICIPANTS: Four focus groups with state-level SNAP administrators and 3 focus groups with state-level SNAP supportive services (Supplemental Nutrition Assistance Program-Education, Employment & Training, and Outreach) supervisors (n = 62). PHENOMENON OF INTEREST: Supplemental Nutrition Assistance Program implementation during the COVID-19 pandemic. ANALYSIS: Thematic analysis using a phronetic iterative approach. RESULTS: Six primary themes emerged: the policy response, technology needs, collaboration, participant communication, funding realities, and equity. Implementation challenges included the design of waivers in the early pandemic response, inadequate federal guidance and funding, outdated technology, and prepandemic regulations limiting state authority. Modernized technology systems, availability of virtual programming, partnerships, and enhanced benefits facilitated SNAP implementation. CONCLUSIONS AND IMPLICATIONS: Supplemental Nutrition Assistance Program administrators adapted their programs to deliver services virtually during the COVID-19 pandemic. These experiences highlighted the importance of certain policy determinants, such as modernized technology and streamlined application processes, to improve outcomes for SNAP participants and staff.

Improving Acetabular Component Positioning in Total Hip Arthroplasty: A Cadaveric Study of an Inertial Navigation Tool and a Novel Registration Method.

Background: Incorrect acetabular component positioning in total hip arthroplasty (THA) has been associated with poor outcomes. Computer-assisted hip arthroplasty increases accuracy and consistency of cup positioning compared to conventional methods. Traditional navigation units have been associated with problems such as bulkiness of equipment and reproducibility of anatomical landmarks, particularly in obese patients or the lateral position. Purpose: We sought to evaluate the accuracy of a novel miniature inertial measurement system, the Navbit Sprint navigation device (Navbit, Sydney, Australia), to navigate acetabular component positioning in both the supine and lateral decubitus positions. We also aimed to validate a new method of patient registration that does not require acquisition of anatomical landmarks for navigation. Methods: We performed THA in a cadaveric study in supine and lateral positions using Navbit navigation to record cup position and compared mean scores from 3 Navbit devices for each cup position on post-implantation CT scans. Results: A total of 11 cups (5 supine and 6 lateral) were available for comparison. A difference of 2.34° in the supine direct anterior approach when assessing acetabular version was deemed to be statistically but not clinically significant. There was no statistically significant difference between CT and navigation measurements of cup position in the lateral position. Conclusion: This cadaveric study suggests that a novel inertial-based navigation tool is accurate for cup positioning in THA in the supine and lateral positions. Furthermore, it validates a novel registration method that does not require the identification of anatomical landmarks.

The Infection Rate of Metal-on-Metal Total Hip Replacement Is Higher When Compared to Other Bearing Surfaces as Documented by the Australian Orthopaedic Association National Joint Replacement Registry.

BACKGROUND: Despite the well-documented decline in the use of metal-on-metal (MoM) implants over the last decade, there are still controversies regarding whether all MoM implants are created equally. Complications such as elevated serum metal ion levels, aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) and pseudotumours have all been well documented, but recent studies suggest increased risk of infection with MoM bearing surfaces. Most of these studies however have small patient numbers. QUESTIONS/PURPOSES: The purpose of this study was to examine the cumulative incidence of revision for infection of MoM bearing surfaces in primary hip arthroplasty at a national and single-surgeon level. METHODS: Data was collected from the Australian Orthopaedic Association National Joint Replacement Registry, which contains over 98% of all arthroplasties performed in Australia since 2001. The cumulative incidence of revision for infection was extracted at a national level and single-surgeon level. RESULTS: Two hundred seventy-six thousand eight hundred seventy-eight subjects were documented in the Australian registry. The 10-year cumulative percent revision for infection of MoM bearing surfaces in primary total hip replacement (THR) was 2.5% at a national level, compared to 0.8% for other bearing surfaces. The senior author contributed 1755 subjects with 7-year follow-up and a cumulative percent revision for infection of MoM bearing surfaces in primary THR of 36.9%, compared to 2.0% for other bearing surfaces. The cumulative percent of revision of MoM bearing surfaces is higher compared to other bearing surfaces; this is especially pronounced in cumulative percent of revision for infection. CONCLUSION: There was a higher cumulative percent of revision for infection in MoM bearings surfaces (in particular, large-head MoM) compared to other bearing surfaces at both the national and individual-surgeon level.

Revision hip arthroplasty using a modular revision hip system in cases of severe bone loss.

We sought to identify outcomes of the Restoration Modular Hip System in cases of severe femoral bone stock deficiency. We performed a retrospective review of 55 revTHAs with a mean follow-up of 32 months (24-60 months). Outcomes included the WOMAC and HHS. Preoperative bone loss was categorized as Paprosky 3A (n = 13), 3B (n = 14), and 4 (n = 17). Periprosthetic fractures were classified as Vancouver B2 (n = 6) and B3 (n = 5). 53 of 55 stems were in situ at time of final review. WOMAC improved from 46 ± 18 to 70 ± 22 and HHS improved from 47 ± 15 to 78 ± 15. Complications were identified in 9 patients, which included dislocation (3), subsidence (2), infection (2), and periprosthetic fracture (2). In cases of significant proximal femoral bone deficiency, this stem demonstrated improvement in clinical outcomes with good results at short-term follow up.

Surgical management of posttraumatic elbow arthrofibrosis.

BACKGROUND: Functional loss of motion is a frequent complication after elbow trauma. The purpose of this study was to determine the effectiveness of open elbow release in restoring functional elbow motion. METHODS: A retrospective chart review of 177 adult patients who underwent open elbow release at our institution by the senior surgeon (D.P.H.) from 2003 to 2010 was performed. Seventy-seven of the elbow contracture releases were performed for posttraumatic elbow stiffness, with loss of flexion-extension. Burns and isolated proximal radioulnar exostosis resections were excluded. The mean age of patients was 45 years (range, 20-76 years), with 68 patients demonstrating radiographic evidence of heterotopic ossification (HO). The mean preoperative flexion-extension arc was 51 degrees. All patients were treated with the same surgical protocol, which included circumferential elbow capsulectomy, HO excision, hardware removal, and ulnar nerve neurolysis with submuscular anterior transposition. RESULTS: At a mean follow-up of 12 months (range, 3-56 months), the mean elbow flexion-extension arc was 109 degrees representing a mean gain of 58 degrees. Sixty-nine percent (53 of 77 patients) achieved a minimum 100-degree functional elbow arc of motion. Six patients (8%) developed recurrent HO, with four undergoing secondary HO excision. One additional patient required manipulation under anesthesia in the early postoperative period. Complications included five infections, one postoperative fracture, one postoperative hematoma, and one radial head implant loosening. CONCLUSION: Open elbow contracture release and HO excision is an effective means of restoring functional elbow range of motion with a low complication rate. Furthermore, recurrent HO formation and elbow arthrofibrosis respond well to repeat surgical excision and contracture release. LEVEL OF EVIDENCE: IV, therapeutic study.

Quantification of global myocardial oxygenation in humans: initial experience.

PURPOSE: To assess the feasibility of our newly developed cardiovascular magnetic resonance (CMR) methods to quantify global and/or regional myocardial oxygen consumption rate (MVO2) at rest and during pharmacologically-induced vasodilation in normal volunteers. METHODS: A breath-hold T2 quantification method is developed to calculate oxygen extraction fraction (OEF) and MVO2 rate at rest and/or during hyperemia, using a two-compartment model. A previously reported T2 quantification method using turbo-spin-echo sequence was also applied for comparison. CMR scans were performed in 6 normal volunteers. Each imaging session consisted of imaging at rest and during adenosine-induced vasodilation. The new T2 quantification method was applied to calculate T2 in the coronary sinus (CS), as well as in myocardial tissue. Resting CS OEF, representing resting global myocardial OEF, and myocardial OEF during adenosine vasodilation were then calculated by the model. Myocardial blood flow (MBF) was also obtained to calculate MVO2, by using a first-pass perfusion imaging approach. RESULTS: The T2 quantification method yielded a hyperemic OEF of 0.37 +/- 0.05 and a hyperemic MVO2 of 9.2 +/- 2.4 micromol/g/min. The corresponding resting values were 0.73 +/- 0.05 and 5.2 +/- 1.7 micromol/g/min respectively, which agreed well with published literature values. The MVO2 rose proportionally with rate-pressure product from the rest condition. The T2 sensitivity is approximately 95% higher with the new T2 method than turbo-spin-echo method. CONCLUSION: The CMR oxygenation method demonstrates the potential for non-invasive estimation of myocardial oxygenation, and should be explored in patients with altered myocardial oxygenation.

Reoperation rate in diaphyseal tibia fractures.

BACKGROUND: Tibia fractures often require secondary surgery to achieve union. Reoperation is an objective outcome measure that is clinically relevant to the patients and treating doctors. This study determined the complication and reoperation rates for diaphyseal tibia fractures and identified variables predictive of reoperation. METHODS: One-hundred and sixty-seven patients with 175 consecutive tibia shaft fractures (Association for the Study of Internal Fixation classification 42) presenting between July 2000 and June 2003 were included in the study. There were 4 deaths and 12 patients lost to follow up. The remaining 151 patients (159 fractures) were reviewed at a minimum of 6 months post-injury for the main outcome measures; union and reoperation. Univariate and multivariate analyses by logistic regression were used to identify any relationship between revision surgery and fracture classification, grade of the soft-tissue injury, mechanism of injury, age, sex, and treating surgeon. RESULTS: The overall reoperation rate was 35.8% (57/159) with 13.2% (21/159) tibiae requiring minor revision surgery and 22.6% (36/159) tibiae requiring major revision surgery. Thirteen (8.2%) patients underwent major revision surgery specifically for non-union. The fracture classification and the Gustilo grade of soft-tissue injury were significant predictors of revision surgery overall, and of major revision surgery. CONCLUSIONS: Tibial shaft fractures have a high revision rate as a consequence of non-union and infection. Revision surgery is best predicted by the fracture classification and the severity of the soft-tissue injury. This information is important for patient information and clinical decision making.