Crisis management for surgical teams and their leaders, lessons from the COVID-19 pandemic; A structured approach to developing resilience or natural organisational responses.

BACKGROUND: Multiple industries and organisations are afflicted by and respond to institutional crises daily. As surgeons, we respond to crisis frequently and individually such as with critically unwell patients or in mass casualty scenarios; but rarely, do we encounter institutional or multi-institutional crisis with multiple actors as we have seen with the COVID-19 pan-demic. Businesses, private industry and the financial sector have been in a more precar-ious position regarding crisis and consequently have developed rapid response strate-gies employing foresight to reduce risk to assets and financial liquidity. Moreover, large nationalised governmental organisations such as the military have strategies in place ow-ing to a rapidly evolving geopolitical climate with the expectation of immediate new chal-lenges either in the negotiating room or indeed the field of conflict. Despite both nation-alised and privatised healthcare systems existing, both appeared ill-prepared for the COVID-19 global crisis. METHODS: A narrative review of the literature was undertaken exploring the approach to crisis man-agement and models used in organisations exposed to institutional crises outside the field of medicine. RESULTS: There are many parallels between the organisational management of private business institutions, large military organisations and surgical organisational management in healthcare. Models from management consultancies and the armed forces were ex-plored discussed and adapted for the surgical leader providing a framework through which the surgical leader can bring about an successful response to an institutional crisis and ensure future resilience. CONCLUSION: We believe that healthcare, and surgeons (as leaders) in particular, can learn from these other organisations and industries to engage appropriate generic operational plans and contingencies in preparation for whatever further crises may arise in the future, both near and distant. As such, following a review of the literature, we have explored a number of models we believe are adaptable for the surgical community to ensure we remain a dy-namically responsive and ever prepared profession.

Manubrium-limited sternotomy decreases blood loss after aortic valve replacement surgery.

OBJECTIVES: Minimally invasive surgical approaches for aortic valve replacement (AVR) are growing in popularity in an attempt to decrease morbidity from conventional surgery. We have adopted a technique that divides only the manubrium and spares the body of the sternum. We sought to determine whether patients benefit from this less-invasive approach. METHODS: We retrospectively analysed our prospectively maintained database to review all isolated aortic valve replacements performed in an 18-month period from November 2011 to April 2013. RESULTS: One hundred and ninety-one patients were identified, 98 underwent manubrium-limited sternotomy (Mini-AVR) and 93 had a conventional median sternotomy (AVR). The two groups were well matched for preoperative variables and risk (mean logistic EuroSCORE mini-AVR 7.15 vs AVR 6.55, P = 0.47). Mean cardiopulmonary bypass and aortic cross-clamp times were 10 and 6 min longer, respectively, in the mini-AVR group (mean values 88 vs 78 min, P = 0.00040, and 66 vs 60 min, P = 0.0078, respectively). Mini-AVR patients had significantly less postoperative blood loss, 332 vs 513 ml, P = 0.00021, and were less likely to require blood products (fresh-frozen plasma and platelets), 24 vs 36%, P = 0.042. Postoperative complications and length of stay were similar (discharge on or before Day 4; mini-AVR 15 vs AVR 8%, P = 0.17). Valve outcome (paravalvular leak mini-AVR 2 vs AVR 1%, P = 1.00) and survival (mini-AVR 99 vs AVR 97%, P = 0.36) were equal. CONCLUSIONS: A manubrium-limited approach maintains outcomes achieved for aortic valve replacement by conventional sternotomy while significantly reducing postoperative blood loss and transfusion of blood products.

Coronary artery bypass grafting is associated with excellent long-term survival and quality of life: a prospective cohort study.

BACKGROUND: We investigated the long-term outcome of coronary artery bypass grafting both in terms of survival and quality of life. METHODS: Ten-year postsurgery survival was collated on patients undergoing coronary artery bypass grafting from 1994 to 1996, and quality of life was assessed using EQ-5D and a quality-of-life thermometer. We analyzed data from 1,180 patients. Mean age was 61 years, and 79% had triple-vessel disease. RESULTS: Thirty-day mortality was 3.3% (1.8% elective). Mean time to censorship for survivors was 9.9 years (range, 8.1 to 12.3 years). Ten-year survival was 66% across all patients, 70% for elective patients. Ten-year cardiac survival was 82%. Percutaneous intervention was required in 25 patients in the subsequent 10 years (2%), and only 4 required redo coronary artery bypass grafting (0.3%); 59% of patients reported no angina, and 88% of patients had grade II angina or better. Of 621 patients who were assessed for quality of life at 10 years, 530 (85%) had a quality of life within a 95% confidence interval of the score found in the general population with similar age. Poor quality of life was reported in 91 patients (14.7%). Significant predictors of poor long-term quality of life were current smoking, Canadian Cardiovascular Society grade III or IV, redo operation, female sex, diabetes, peripheral vascular disease, more than 2 days in intensive care, and chronic obstructive pulmonary disease. Twenty-five percent of patients with poor EQ-5D outcome had grade IV angina. Interestingly, age did not correlate with poor outcome, and administration of blood, arterial revascularization, left mainstem disease, or cross-clamp fibrillation had no impact on survival or outcome. CONCLUSIONS: Coronary artery bypass grafting is associated with excellent 10-year survival and quality of life.

Coronary bypass grafting using crossclamp fibrillation does not result in reliable reperfusion of the myocardium when the crossclamp is intermittently released: a prospective cohort study.

BACKGROUND: Cross-clamp fibrillation is a well established method of performing coronary grafting, but its clinical effect on the myocardium is unknown. We sought to measure these effects clinically using the Khuri Intramyocardial pH monitor. METHODS: 50 episodes of cross-clamping were recorded in 16 patients who underwent CABG with crossclamp-fibrillation. An Intramyocardial pH probe measured the level of acidosis in the anterior and posterior myocardium in real-time. The pH at the start and end of each period of cross-clamping was recorded. RESULTS: It became very apparent that the pH of some patients recovered quickly while others entirely failed to recover. Thus the patients were split into 2 groups according to whether the pH recovered to above 6.8 after the first crossclamp-release (N = 8 in each group). Initial pH was 7.133 (range 6.974-7.239). After the first period of crossclamping the pH dropped to 6.381 (range 6.034-6.684). The pH in recoverers prior to the second XC application was 6.990 (range 6.808-7.222) compared to only 6.455 (range 6.200-6.737) in patient's whose myocardium did not recover (P < 0.0005). This finding was repeated after the second XC release (mean pH 7.005 vs 6.537) and the third (mean pH 6.736 vs 6.376). However prior to separation from bypass the pH was close to the initial pH in both groups (7.062 vs 7.038). CONCLUSION: Crossclamp fibrillation does not result in reliable reperfusion of the myocardium between periods of crossclamping.

Use of intraaortic balloon pump in left ventricle rupture after mitral valve replacement.

Over 6 years of a single surgeon experience, 3 patients had left ventricle rupture following mitral valve replacement, despite preserving the posterior leaflet. The valve was re-replaced on bypass in all patients. Intraaortic balloon pump was inserted electively before coming off bypass. There were no intraoperative deaths, reexploration, or excessive bleeding. An intraaortic balloon pump is an ideal adjuvant to left ventricle repair for ruptured ventricle following mitral valve replacement on cardiopulmonary bypass.

Magnetic resonance imaging of calcaneal aneurysmal bone cyst.

A 7-year-old black male presented with a lytic, expansile lesion of the calcaneus. This lesion was studied with conventional x-rays as well as MRI. The MR examination demonstrated a multiloculated lesion with material of a high- and low-signal intensity appreciated within each loculation. Pathologic review of the lesion demonstrated an aneurysmal bone cyst.

The effect of shear fatigue on bovine articular cartilage.

The objective of this study was to investigate the effects of mechanical fatigue in the form of cyclic shear strain on articular cartilage. Three millimeter diameter full-thickness plugs were cored from the lateral aspect of bovine tibial plateaus. Sinusoidal shear strains of +/- 5, +/- 10, and +/- 15% were applied to the specimens at 100 Hz for 3 h (a total of 108 x 10(4) cycles). The mechanical shear properties of the tissue (loss and storage moduli) were determined as a function of the number of applied strain cycles. A rapid, irreversible decrease of approximately 35% of initial modulus was found to occur in both loss and storage modulus during application of the first 90,000 cycles. Further decay in the moduli was found to occur from 90 x 10(3) to 108 x 10(4) cycles, but was of considerably smaller magnitude than the initial decrease. The moduli remained relatively constant beyond application of 108 x 10(4) cycles. No consistent change in proteoglycan content was found to be associated with the fatigue process when comparing tested specimens with fresh, untested tissue, and with experimental controls. In addition, no structural defects in the mechanically altered tissue were revealed by scanning electron microscopy.

Juvenile fracture of tillaux. A distal tibial epiphyseal fracture.

The juvenile fracture of Tillaux is a Salter-Harris type III fracture of the distal tibial epiphysis. The mechanism of injury is an external rotational force of the foot. The fracture fragment is avulsed from the anterolateral aspect of the distal tibial epiphysis by the anteroinferior tibiofibular ligament. Treatment is based on the amount of displacement after closed reduction techniques are attempted. If complete anatomical reduction cannot be obtained, the authors recommend open reduction with internal fixation. The method of internal fixation should be based on the skeletal maturity of the distal tibial epiphysis. The prognosis usually is good if anatomical reduction is performed. The most serious complication reported is pain and stiffness secondary to articular incongruity following inadequate closed reduction techniques. The case of a 14-year-old girl with a juvenile Tillaux fracture treated by open reduction with excellent functional results at 11 months follow-up was presented.

Clinical imaging with indium 111 oxine-labeled leukocyte scan: review and case report.

The clinical use and mechanisms of action of technetium 99m pyrophosphate, gallium 67 citrate, and indium 111 oxine have been presented. The diagnosis of osteomyelitis in the lower extremity can often be made on the basis of clinical, laboratory, and conventional radiographic evaluations. In the case report of diabetic osteolysis, initial evaluations revealed osteomyelitis. The use of scanning involving leukocytes labeled with technetium and indium 111 oxine lessened the possibilities of an osseous infection. Studies show the sensitivity, specificity, and accuracy of scans using leukocytes labeled with indium 111 oxine to be superior to those of any other form of nucleotide imaging, but further clinical research is needed.

Water content of equine articular cartilage: effects of enzymatic degradation and "artificial fibrillation".

A method is described for accurate and reproducible determination of wet and dry weights of small articular cartilage samples. The water content of the articular cartilage samples before and after treatment with selective degradative enzymes and "artificial fibrillation" was determined. It was found that the water content of articular cartilage can be altered by changing the physical and chemical composition of articular cartilage. The combination of protein polysaccharide degradation and "fibrillation" causes an increase in articular cartilage water content, while collagenase and the combination of collagenase and "fibrillation" causes a decrease. The relationship between these findings and function of normal and osteoarthritic cartilage is discussed.

Pathogenesis of degenerative joint disease produced by in vivo freezing of rabbit articular cartilage.

In vivo freezing of rabbit lateral femoral arterial cartilage with a cryoprobe produces an osteoarthritic-like condition in 12 months. Previous studies have established that the chondrocytes are killed by the freezing process. A loss of stainable mucopolysaccharide occurs. The collagen content of the lesional tissue does not change. The present study investigates the extracellular lysosomal enzyme content, collagen type (I or II), and histologic changes which produce chondrocyte cell clusters in the frozen tissue in response to freezing or articular cartilage. The results indicate that after the initial 30 days there is no significant rise in the extracellular lysosomal enzyme content of the experimental tissue compared with controls. Type II, or cartilage, collagen remains the major constituent of the lesional tissue. Histologic examination at six- to 12-month intervals suggests that chondrocyte clones are produced by invasion by the underlying viable subchondral bone. These results provide insight into the pathogenesis of degenerative joint disease and the rationale of treatment by the use of inhibitors of vascular invasion of articular cartilage.

Long-term effects of chondrocyte death on rabbit articular cartilage in vivo.

The effects of freezing localized areas of rabbit articular cartilage in vivo were studied at two to twelve months morphologically (gross and microscopic examination, including scanning electron microscopy), histochemically (toluidine blue and safranin O), and metabolically (35S uptake). Up to six months the frozen cartilage was intact but appeared to be dead, as shown by the absence of stainable chondrocytes, severely decreased acid mucopolysaccharide content, and absence of significant uptake of 35S. At twelve months fibrillation and softening were evident, clusters of new chondrocytes with surrounding acid mucopolysaccharides were visible microscopically, and scanning electron microscopy revealed an irregular pattern of collagen fibers which were larger than normal, of varying thickness, and broken in some areas. These changes resembled those seen in degenerative joint disease.

Instrcapsular epiphyseal osteoid osteoma of ankle joint. A case report.

A 12-year-old boy with ankle pain following minor trauma was found after a month of conservative treatment to have a small sclerotic lesion in the anterolateral distal tibial epiphysis. At operation, a vascular, raised, intracapsular epiphyseal lesion was removed. Microscopic examination revealed an osteoid osteoma. To the authors' knowledge no previous example of intracapsular epiphyseal osteoid-osteoma has been reported.

Soft tissue disorders of the shoulder. Frozen shoulder, calcific tendintis, and bicipital tendinitis.

The painful periarticular conditions about the shoulder joint-calcific tendinitis, bicipital tendinitis, and frozen shoulder syndrome-are seen commonly in the general practice of medicine or in the practice of orthopedic surgery. Their etiologies are unknown. Their treatment is relatively simple and depends upon a knowledge of the anatomic structures involved and the proper use of rest and exercise. Operative intervention is rarely necessary in any of these conditions. The frozen shoulder syndrome, however, in our experience is best treated in the subacute or chronic stages by infiltration brisement under general anesthesia.