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PubMed1997

Rethinking postoperative diets for short-stay orthopedic surgery patients.

OBJECTIVE: To examine postoperative meal tolerance and meal preferences of short-stay orthopedic surgery patients. DESIGN: A patient survey was designed with input of nurses and former patients. Patient interviews focused on the first two meal trays provided, fluids offered, and perceived hunger after surgery. SUBJECTS/SETTING: Subjects (n = 31) were adult orthopedic inpatients who were within 24 hours of surgery conducted while they were under general anesthetic and who had received at least one postoperative meal tray. STATISTICAL ANALYSES PERFORMED: Descriptive statistical procedures were performed and chi 2 tests were used to compare responses at the first and second meals. RESULTS: At the first meal after surgery, most patients reported adverse postoperative symptoms. Twenty-six (84%) patients had received regular meals. Fifteen (48%) patients reported eating almost nothing, yet 12 (39%) reported eating most or all food provided. Twenty-six (84%) patients thought a meal consisting of a combination of fluid and solid items would have been acceptable. At the second postoperative meal, fewer adverse symptoms were reported. Accordingly, most patients were able to eat the regular meal and considered solid food appropriate. Twenty-nine (94%) patients thought the amount of fluid provided after surgery was adequate. Eight (26%) patients reported feeling unreasonably hungry at some point after surgery. APPLICATIONS/CONCLUSIONS: Short-stay orthopedic surgery patients recover quickly from general anesthesia; however, patients vary in postoperative symptoms, meal tolerance, and meal preferences. Findings from this survey were applied to the development of a postoperative meal protocol, now in use, that features meals containing a combination of solid and fluid items.

Adult↗
PubMed1995

Blood management in orthopedic surgery.

The orthopedic surgeon has several options available for blood conservation. Preoperative autologous donation (PAD) of blood is a cost-effective measure when the cost of managing transfusion-transmitted infectious disease is considered; overuse and underuse are expensive problems, however. Hemodilution, while used successfully in prostate surgery, is logistically impractical in joint replacement centers. Intraoperative blood salvage, although costly, is useful in orthopedic procedures when the anticipated blood loss is > 1,000 mL. Reinfusion of postoperative drainage that has been filtered and washed is being used in some orthopedic procedures. Studies are under way to determine whether this method of blood conservation alters transfusion requirements. Recombinant human erythropoietin (Epoetin alfa) has a role in elective procedures with significant blood loss, including complex revision joint replacement, bilateral joint arthroplasty, and spinal fusion. Preoperative Epoetin alfa administration enhances preoperative autologous blood collection and increases perioperative red blood cell mass.

Blood Loss, Surgical↗
PubMed1998

Outpatient pediatric orthopedics. Common and important conditions.

Many common pediatric orthopedic conditions can be managed by the pediatrician who has a knowledge of the natural history of these conditions. An accurate diagnosis is necessary to provide proper treatment, give advice to patients, or make referrals to the proper specialist. The authors' find that in approximately 95% of cases, a specific diagnosis can be made and that 40% of patient referrals for orthopedic problems could have been managed by the primary care physician. This article discusses some of the more common pediatric orthopedic problems often encountered by primary care physicians.

Adolescent↗
PubMed1987

Major ambulatory surgery of the orthopedic patient.

Orthopedic procedures that have been performed satisfactorily in an ambulatory setting are described. Ambulatory orthopedic surgery involves the same principles as inpatient orthopedic surgery. Explicit postoperative instructions to the patient and family member and the postoperative dressing are two factors of great importance in the ambulatory unit.

Ambulatory Surgical Procedures↗
PubMed2001

Efficacy and tolerability of celecoxib versus hydrocodone/acetaminophen in the treatment of pain after ambulatory orthopedic surgery in adults.

BACKGROUND: Current outpatient management of postoperative pain includes the use of oral opioid analgesics or nonsteroidal anti-inflammatory drugs; however, both types of medications are associated with side effects that can limit their usefulness in the outpatient setting. OBJECTIVE: Two studies with identical protocols assessed the single- and multiple-dose analgesic efficacy and tolerability of celecoxib, a specific cyclooxygenase-2 inhibitor, in the treatment of acute pain after orthopedic surgery. METHODS: These were multicenter, randomized, placebo- and active-controlled, double-blind, parallel-group trials conducted between January and June 1998. Both consisted of a single-dose assessment period (SDAP) and a multiple-dose assessment period (MDAP). In the SDAP, patients who had undergone orthopedic surgery received a single oral dose of celecoxib 200 mg, hydrocodone 10 mg/acetaminophen 1000 mg, or placebo within 24 hours after the end of anesthesia, with pain assessments conducted over the following 8-hour period. In the MDAP, extending from 8 hours after the first dose of study medication up to 5 days, patients who had received < or =1 dose of rescue medication during the SDAP continued on study medication (placebo recipients were rerandomized to active treatment), which could be taken up to 3 times a day as needed. RESULTS: A total of 418 patients were enrolled in the 2 trials. During the SDAP, 141 patients received celecoxib, 136 received hydrocodone/acetaminophen, and 141 received placebo. During the MDAP, 185 patients received celecoxib and 181 received hydrocodone/acetaminophen. When the combined data were analyzed, mean pain intensity difference (PID) scores generally favored the active treatments over placebo from 1 to 6 hours (with the exception of 1.5 hours) after dosing (P < or = 0.016) and favored celecoxib over the other treatments at 7 and 8 hours after dosing (P < 0.001). The active treatments demonstrated superior summed PID scores through 8 hours (P < 0.001), significantly shorter median times to onset of analgesia (P < 0.05), and significantly longer median times to first use of rescue medication (P < 0.05). During the MDAP, more hydrocodone/acetaminophen-treated patients (20%) than celecoxib-treated patients (12%) required rescue medication (P < 0.05), and the celecoxib group had significantly lower maximum pain intensity scores (P < 0.001, days 2-5), required fewer doses of study medication (P < or = 0.01, days 3-5), and had superior scores on a modified American Pain Society Patient Outcome Questionnaire (P < or = 0.013). In addition, a significantly lower proportion of celecoxib-treated patients experienced adverse events (43%) compared with hydrocodone/acetaminophen-treated patients (89%; P < 0.001). CONCLUSIONS: Over 8 hours, patients with moderate to severe pain after orthopedic surgery experienced comparable analgesia with single doses of celecoxib and hydrocodone/acetaminophen. Over a 5-day period, oral doses of celecoxib 200 mg taken 3 times a day demonstrated superior analgesia and tolerability compared with hydrocodone 10 mg/acetaminophen 1000 mg taken 3 times a day. Most patients required no more than 2 daily doses of celecoxib 200 mg for the control of their postorthopedic surgical pain.

Acetaminophen↗
PubMed1996

Analgesic practice for acute orthopedic trauma pain in Costa Rican emergency departments.

STUDY OBJECTIVE: Studies in US emergency departments have demonstrated that pain is undertreated in adults and children. Previous studies have also demonstrated cultural differences in the expression and perception of pain. The objective of this investigation was to describe the analgesic practices and patient pain responses in two Costa Rican EDs in light of possible differences due to cultural variation. METHODS: We carried out a prospective, noninterventional observational assessment protocol of a convenience sample of patients being treated for orthopedic trauma in two university-affiliated urban teaching hospital EDs. Children between the ages of 5 and 12 years and all adults, ages 16 to 63, who presented with painful orthopedic trauma were included. Patients quantified their pain on arriving at and before leaving the ED. Children used a Face Interval Scale ranging from 1 (no pain) to 9 (maximum pain), and adults used a numeric rating scale ranging from 0 to 10. RESULTS: One fourth of pediatric and more than half of all adult patients had no reduction in their pain scores on leaving the ED. Eleven percent of adults and fewer than 4% of children received pain treatment while in the ED. Fewer than half of all patients were sent home with analgesics. We observed no use of opioids in the ED for analgesia. CONCLUSION: Our data illustrate that both adults and children with severe pain resulting from orthopedic injury in the Costa Rican EDs we studied often receive inadequate or no analgesic treatment. This finding suggests that the phenomenon of oligoanalgesia is more widespread and resistant to cultural differences. We also noted a reluctance to use opioids in this setting.

Acute Disease↗
PubMed2001

The effect of transdermal nitroglycerin on spinal S(+)-ketamine antinociception following orthopedic surgery.

STUDY OBJECTIVES: To determine whether combination of transdermal nitroglycerine (a nitric oxide generator) would enhance analgesia from epidural S(+)-ketamine (a N-methyl-D-aspartate antagonist) in patients undergoing orthopedic surgery with combined spinal anesthesia. DESIGN: Randomized, double-blind study. SETTING: Orthopedic surgery unit of a teaching hospital. PATIENTS: 60 ASA physical status I and II patients scheduled for minor orthopedic knee surgery. INTERVENTIONS: Patients were randomized to one of five groups (n = 12) to receive combined epidural/intrathecal anesthesia. A 10-mL epidural injection was first administered to all patients (study drug or normal saline). Intrathecal anesthesia consisted of 15 mg bupivacaine. Twenty to 30 minutes after the spinal puncture, a transdermal patch of either nitroglycerin 5 mg or placebo was applied. The control group (CG) received epidural saline and transdermal placebo. The nitroglycerin group (NG) received epidural saline and transdermal nitroglycerine patch. The 0.1 mg/kg S(+)-ketamine epidural group (1 KG) received 0.1 mg/kg epidural S(+)-ketamine and transdermal placebo. The 0.2 mg/kg S(+)-ketamine epidural group (2 KG) received 0.2 mg/kg epidural S(+)-ketamine and transdermal placebo. Finally, the nitroglycerin/0.1 mg/kg S(+)-ketamine epidural group (1 NKG) received 0.1 mg/kg epidural S(+)-ketamine and transdermal nitroglycerin. Pain and adverse effects were evaluated using a 10-cm visual analog scale (VAS). MEASUREMENTS AND MAIN RESULTS: The groups were demographically the same. Sensory anesthetic level and VAS score for pain at the time of first rescue medication were similar among groups. The time to first rescue analgesic (min) was less in both the CG and the NG groups compared with the other groups (p < 0.05). Epidural S(+)-ketamine resulted in analgesia to both groups (1 KG < 2 KG; p < 0.05). The 1 NKG and the 2 KG displayed similar analgesia (p > 0.05). The CG required more rescue analgesics in 24 hours compared with the patients who received epidural S(+)-ketamine (p < 0.02). CONCLUSIONS: Epidural S(+)-ketamine resulted in antinociception, which was enhanced by transdermal nitroglycerin.

Adjuvants, Anesthesia↗
PubMed1998

Orthopedic management of neuromuscular disorders in children.

In many cases, the orthopedic surgeon may be the first consultant requested to assess complaints of lower extremity weakness or deformity to result from such conditions and must remain alert to the primary diagnosis. In addition, the orthopedic surgeon should be prepared to guide appropriate physical therapy, prescribe orthotics, and perform surgery to improve function, prevent deformity, or provide comfort when necessary. Most deformities of the extremities result from a combination of muscle weakness and imbalance, and surgical procedures are aimed at correcting existing deformity and rebalancing existing musculature by release or transfer. Skeletally immature patients with neuromuscular disorders are also susceptible to the development of scoliosis, which may impair comfortable sitting or already compromised pulmonary function. This article reviews the clinical manifestation and orthopedic management of Duchenne's muscular dystrophy, spinal muscular atrophy, facioscapulohumeral dystrophy, and Charcot-Marie-Tooth disease.

Adolescent↗
PubMedDate not supplied

Prophylactic antibiotics in pediatric orthopedic surgery: current practices.

A limited survey of 90 orthopedic surgery programs throughout the U.S.A. was conducted to determine the use of prophylactic antibiotics in pediatric orthopedic operations. Prophylaxis was used most often in the Harrington rod procedure (80.7%); less often in hip (64.2%) and knee (44.7%) reconstructive surgery; rarely in meniscus repairs (8.0%) and in lengthening of Achilles tendons (2.3%). Cephalosporins (85%) were the antibiotics prescribed most frequently. The first dose was administered before surgery in 89.6% of the operations. Prophylaxis was discontinued within five days in 96% of the operations. These data provide a pattern of the use of prophylaxis in pediatric orthopedic surgery.

Adolescent↗
PubMed1999

Transfusion of buffy coat-depleted blood components and risk of postoperative infection in orthopedic patients.

BACKGROUND: Allogeneic blood transfusions have been reported to increase susceptibility to postoperative infection, but the findings were inconclusive. This study was designed to investigate the effect of buffy coat-depleted allogeneic and autologous transfusion on postoperative infection in patients undergoing orthopedic surgery. STUDY DESIGN AND METHODS: Patients (n = 385) undergoing elective orthopedic surgery (primary and revision joint replacement, spinal, or pelvic surgery) were included in a prospective observational study of the incidence of postoperative infection between April and December 1996. Infection rates in patients who received allogeneic buffy coat-depleted blood transfusions were compared with those in patients who received no transfusion or only autologous (buffy coat-depleted) blood. RESULTS: Patients without exposure to allogeneic blood (no blood or only autologous blood) had an infection rate of 3.9 percent, as compared to a rate of 12.2 percent for those with exposure to allogeneic blood (allogeneic blood, autologous plus allogeneic blood) (odds ratio 3.442; 95% CI, 1.349-10.40; p = 0.006). Of the 385 study patients, 309 underwent primary hip or knee replacement surgery. In this homogeneous subgroup, the postoperative infection rate was 4.6 percent after no transfusion or autologous transfusion and 11.9 percent after allogeneic transfusion (odds ratio 2.827; 95% CI 1.059-8.799; p = 0.036). Multivariate regression analysis confirmed buffy coat-depleted allogeneic blood transfusion as an independent variable associated with high risk for postoperative infection. CONCLUSION: Buffy coat-depleted allogeneic blood transfusion increases the incidence of postoperative infection in patients undergoing uncontaminated orthopedic surgery.

Aged↗
PubMed2002

Detection and removal of fat particles from postoperative salvaged blood in orthopedic surgery.

BACKGROUND: Although transfusion or return of salvaged shed blood has become popular in major orthopedic procedures, this blood-saving method is still controversial because shed blood may be contaminated with chemical and tissular debris, such as fat particles, which may increase the risk of fat embolism after bone surgery. STUDY DESIGN AND METHODS: In an effort to find an easy, reliable method for determination of both fat particle content and removal from shed blood, analyses of perioperative blood samples were performed with a cell counter (Technicon H3 [H3]) in orthopedic patients undergoing spinal fusion in which postoperative shed blood was collected and returned with a blood collection canister. A screen or surface filter was intercalated in the return line to eliminate microaggregates, fat particles, and/or WBCs. RESULTS: Fat particles in shed blood are clearly detected as a condensed, sigmoidal-shaped area at the right-hand side of the PMN zone in the channel in which the H3 measures particles according to their degree of lobularity. This signal can be reproduced by the addition of animal or vegetable fat to venous blood, but not by the addition of activated platelets or RBC membranes. Fat particles, together with WBCs and microaggregates, in shed blood were effectively removed by surface filters, whereas screen filters were not effective. CONCLUSION: The use of the TH3 seems to be an easy, reliable, and low-cost approach for monitoring fat particle content and removal from postoperative salvaged shed blood in orthopedic procedures.

Blood↗
PubMed2004

Strategies for minimizing blood loss in orthopedic surgery.

Several major orthopedic surgical procedures including hip arthroplasty, femoral osteotomy, and spinal fusion may result in significant blood loss and the need for allogeneic blood transfusions. Due to the heightened awareness of the potential deleterious effects of allogeneic blood product administration, several techniques have been evaluated to determine their efficacy in limiting perioperative blood loss. The following article will discuss the options to limit the need for allogeneic blood product administration during orthopedic surgical procedures. These techniques include: general considerations, autologous transfusion therapy, intraoperative and postoperative blood salvage, pharmacologic manipulation of the coagulation cascade, and controlled hypotension. Undoubtedly, many of these techniques are effective alone; however, the goal of performing major orthopedic surgical procedures without the use of allogeneic blood products can only be accomplished by combining several of these techniques.

Aminocaproic Acid↗
PubMed2005

Small area variation in orthopedics.

It is clear that small area variation exists in orthopedics, but there is still much to learn. Given the many unanswered questions regarding area variation, regulatory policy at this time would be premature. The biggest piece of the puzzle that needs to be solved is the influence of disease prevalence and severity. While it seems unlikely this will explain all of the variation, it is equally unlikely that musculoskeletal diseases are distributed evenly across geopolitical boundaries, hence, it likely accounts for some of the observed variation. More patient-level studies need to be conducted in non-Medicare populations. For example, the extent to which area variation exists in sports medicine and knee surgery for younger patients is unknown. Profiling is likely here to stay. In accord, it should be exploited by the orthopedic community for its strengths while keeping in mind its limitations. Orthopedic surgeons should be at the forefront of this research and consequently influential in its evolution rather than have the managed care industry or government dictate policy.

Health Services Needs and Demand↗
PubMed2002

Technical considerations: CT and MR imaging in the postoperative orthopedic patient.

Cross-sectional imaging utilizing computed tomography (CT) and magnetic resonance (MR) imaging have become routine components in the imaging assessment of patients with musculoskeletal disease. Unfortunately, in the setting of a postoperative orthopedic patient with associated orthopedic metallic instrumentation, these imaging techniques are prone to artifacts resulting in image quality degradation. An understanding of the physical basis of such metal-related artifacts, and their appearance on CT and MR imaging, has led investigators to the implementation of a series of techniques and modifications to imaging protocols to decrease CT and MR imaging artifacts in the vicinity of metallic instrumentation. Utilizing such modified imaging techniques, consistent, improved CT and MR image quality may be achieved in imaging of the postoperative orthopedic patient.

Artifacts↗
PubMed2006

[Indications for use of the V.A.C.-system in the orthopedic surgery].

INTRODUCTION: The vacuum-assisted closure (V.A.C.)-therapy is accepted for an efficient option in the treatment of infected wounds with healing complications. However, reports on its use in the septic orthopedic surgery are seldom. Hence, the aim of this study is to demonstrate our experience with the V.A.C.-system in the treatment of orthopedic-related infections. PATIENTS-METHODS: Various musculoskeletal infections with prolonged wound healing (infections after Achilles tendon reconstruction, fibula osteosynthesis, dorsal spondylodesis, and total hip arthroplasty, skin necrosis after total knee arthroplasty and wound dehiscence after resection and irradiation of a liposarcoma) have been treated with the V.A.C.-device. After infection sanitation we performed skin graft transplantation in 3 cases for definitive wound closure, also assisted by the V.A.C.-therapy. RESULTS: An infection eradication with implant preservation, where necessary, could have been achieved in all cases. No complications were observed in the cases with the skin graft transplantations. No infection persistence or reinfection occurred at a mean follow-up of 36 months. DISCUSSION: The V.A.C.-therapy seems to be a valuable adjunct in the treatment of infected wounds in the orthopedic surgery, however, definitive conclusion should await the results of future clinical studies with large series.

Aged↗
PubMed2006

Multichannel CT Imaging of Orthopedic Hardware and Implants.

The introduction of multichannel CT scanners provides both radiologists and surgeons with a new tool to image patients with orthopedic hardware. The key parameters that have made it possible to image the implants and the surrounding bone with multichannel CT are the higher available technical factors (kVp and mAs) coupled with the ability to acquire thin slices over a large scan region. These properties make it possible to produce high-quality multiplanar reformations that facilitate visualization of the orthopedic device and the surrounding bone. An important consideration for multichannel CT imaging of hardware is the reduction of cone beam artifacts caused by the geometry of multichannel CT scanners. This artifact is reduced by using a narrower x-ray beam collimation and a low pitch setting. This article discusses CT scan parameters and image postprocessing used at our institution and illustrates common clinical problems encountered when imaging implanted orthopedic devices. These include fracture healing, loosening of joint prostheses, evaluation of particle disease, and the use of CT for preoperative planning in revision arthroplasty.

Equipment Failure↗
PubMedDate not supplied

[The hospital service misuse problem in orthopedics].

In a representative study for all German acute hospitals the amount of inappropriate (medically not necessary) patient care was estimated. The data material, sampling design, weighting technic and the appropriateness expert rating (retrospective, consent judging) was controlled. An overall proportion of inappropriate days of care of 18.45% were found but for orthopedic diseases this rate was 31.9% and even 37.7% for the younger than 60 orthopedic patients. Similar high rates for orthopedic diseases were found in US hospital studies of inappropriateness and should lead to an analysis of their reasons.

Bed Occupancy↗
PubMedDate not supplied

[Use of electronic data processing in larger orthopedic clinics. Results of a survey].

In a survey of 93 orthopedic clinics or departments conducted in 1985, concerning the use of data processing systems, a total of 64 replies were received. These were not yet affected by the new Federal (German) Hospital Tariffs Regulations and therefore reflect the actual needs of the institutions in question. There is a clear trend toward using data processing for scientific purposes. Data processing systems were already in use in 42 institutions. There are hardly any differences between university clinics and non-university establishments. It is significant that among the key systems used in orthopedic medicine, ICD9 plays a completely subordinate role. This is seen as proof that ICD9 is inadequate for orthopedic purposes. Attention is drawn to a simple diagnostic key used by the Oskar-Helene-Heim. The author also comments on the problems of special documentation departments.

Electronic Data Processing↗