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PubMed2006

Evaluation of cardiac involvement following major orthopedic surgery.

BACKGROUND: Cardiovascular morbidity is frequent after non-cardiac surgery and the early recognition of cardiac involvement is an essential tool for clinical risk stratification and management. The aim of this study was to investigate the behavior of traditional and emerging cardiac markers, including NT-prohormone-brain natriuretic peptide (NT-proBNP) and ischemia-modified albumin (IMA), in the perioperative period in patients undergoing major uncomplicated orthopedic surgery. METHODS: A total of 37 patients undergoing major orthopedic surgery were longitudinally evaluated for NT-proBNP, IMA, cardiac troponin T (cTnT), creatine kinase isoenzyme MB and myoglobin 3 h before surgery and 4 and 72 h thereafter. RESULTS: NT-proBNP values were significantly increased at 72 h postoperative compared to both 3 h preoperative and 4 h postoperative (NT-proBNP: 20 vs. 4.5 pmol/L, p<0.001 and 20 vs. 5.9 pmol/L, p<0.001). IMA levels were significantly increased at 4 and 72 h postoperative vs. 3 h preoperative (132 vs. 113 kU/L, p=0.02 and 151 vs. 113 kU/L, p<0.001). In a stepwise regression model, the perioperative liquid amount and degree of modification in postoperative creatinine levels (delta-creatinine) were independently related to the NT-proBNP increase. CONCLUSIONS: The significant increase observed in NT-proBNP suggests that patients undergoing major uncomplicated orthopedic surgery may develop subclinical cardiac stress, presumably attributable to the considerable infusion of liquids. The clinical significance of this finding deserves further investigation, especially in patients at higher risk of heart failure.

Adolescent↗
PubMed2001

Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip, and alveolus of infants born with unilateral and bilateral clefts.

This addendum to the "State of the Art Dental Treatment of Predental and Infant Patients With Clefts and Craniofacial Anomalies," by Prahl-Andersen (Cleft Palate Craniofac J. 2000;37:528532), offers an extended perspective on this controversial subject. This article reviews the role of combined nasal and alveolar (nasoalveolar) molding in the primary correction of the nose, lip, and alveolus of infants born with unilateral and bilateral clefts. The background of presurgical nasoalveolar orthopedic molding, the technique, and the literature are presented. The proposed benefits of treatment from the traditional techniques of presurgical orthopedics have been shown to be unsubstantiated (Kuijpers-Jagtman and Prahl, 1996). A close comparison of the proposed benefits of earlier forms of presurgical orthopedics, along with those of the current technique of nasoalveolar molding, is presented.

Alveolar Process↗
PubMed2006

[Incidence of surgical site infections in the departments of orthopedics and traumatology].

BACKGROUND/AIM: Besides infections of urinary tract and pneumonias, as well as blood infections, surgical site infections (SSI) represent one of the most common localization of hospital infections. The aim of this study was to determine the incidence of SSI in the departments of orthopedics and traumatology as well as the SSI incidence in relation to the ASA score, surgical site contamination class and NNIS index. METHODS: A prospective cohort study followed daily all the surgical patients hospitalized over 48 hours in the Institute for Orthopedic Surgery and Traumatology, Clinical Center of Serbia, as well as 30 days after the discharge, during the period betwen February 1 to July 31, 2002. The patients were examined and their diagnoses made according to the definition of hospital infections, i.e. upon clinical and/or laboratory analyses, using concurrently the ASA score, surgical site contamination class and NNIS index. RESULTS: Out of 227 surgical patients, 60 were diagnosed with SSI during their hospitalization, while 3 of the patients developed SSI after the discharge. The incidence of SSI was 22.7% (95% CI = 17.8-27.6). In the patients with good health condition, i.e. ASA < or = 2, the incidence of SSI was 18.3% (43/235) and in those with ASA > 2, it was 47.6% (20/42) (chi2 = 17.4; p < 0.001). The incidence of SSI was 13.5% (25/185) in the clean wounds, 11.6% (5/43) in purely contaminated, while it was much higher in the contaminated 65.5%; (19/29) and soiled 70.0%; (14/20) wounds (chi2 = 67.6; p < 0.001). The incidence of SSI in relation to NNIS was 8.1% (13/161) in the patients with score 0, then 36.4% (32/88) in the patients with score 1, and 64.3% (18/28) in the patients with the scores 2 and 3 (chi2 = 57.3; p < 0.001). The patients with SSI stayed in the departments of orthopedics and traumatology approximately 1.8 times longer than the patients without SSI (t = 5.3; DF = 275; p < 0.0019. CONCLUSION: It is important to emphasize the need for constant epidemiological surveillance of SSI and the implementation of preventive measures in Serbia.

Adolescent↗
PubMed1991

Orthopedic research and education in Scandinavia.

Based upon an enquiry conducted in 1988 and 1989, data on the resources for orthopedic research in Scandinavia are presented, supplemented with a survey of the number of scientific papers published from Scandinavia in major orthopedic journals. The postgraduate training programs for orthopedic surgeons in the Scandinavian countries are outlined.

Education, Medical, Graduate↗
PubMed1989

Orthopedic research: an overview of data entry, database management, and statistical analysis.

An orthopedic practitioner can facilitate clinical research and analyze quality assurance data with a minor investment in a personal computer, an optical scanner, and two software packages, namely a database manager and a statistics program. One of the most time-consuming stages in the research process includes entering patient chart data, editing and manipulating the data (database management), and analyzing the data (statistical analysis). This can be automated to a large extent with the above mentioned equipment. This article focuses on the steps involved in organizing an orthopedic office for research. The steps include choosing a method of data entry, choosing and implementing a database package, and choosing and implementing a statistics package. This discussion is followed by a practical review of basic statistics applicable to orthopedic research. Several simple and advanced tests are described and examples are given for each.

Biometry↗
PubMed2003

Anesthesia and postoperative analgesia: outcomes following orthopedic surgery.

The demand for increased efficiency and decreased hospital stay has magnified the role of anesthesia and acute postoperative pain management in orthopedics. Orthopedic anesthesia and acute postoperative pain management, which are subspecialties of anesthesiology, are increasingly recognized for their positive effect on the length of hospital stay, functional recovery, and patient satisfaction. Recently, there has been a resurgence in the use of continuous nerve block techniques for postoperative pain management. These techniques have been shown to be effective and safe in controlling postoperative pain, both at rest and during physical therapy, even in anticoagulated patients. The use of peripheral nerve blocks for anesthesia has been associated with earlier discharge when compared with general anesthesia and neuraxial blocks in patients undergoing ambulatory orthopedic surgery. Regional techniques are usually part of a multimodal strategy that includes both pharmacological and nonpharmacological approaches to pain management.

Adult↗
PubMed2006

Venous thromboembolism following major orthopedic surgery: what is the risk after discharge?

Guidelines recommend thromboprophylaxis for at least 10 days to prevent venous thromboembolism in patients undergoing high-risk orthopedic surgery, such as total hip arthroplasty (THA) or total knee arthroplasty (TKA). Furthermore, the recently updated ACCP guidelines also recommend extending the duration of thromboprophylaxis for 28 to 35 days following THA or hip fracture surgery as the risk for venous thromboembolism persists for up to 3 months after surgery. Extended-duration thromboprophylaxis (up to 6 weeks) with low-molecular-weight heparin is significantly more effective in preventing venous thromboembolism in orthopedic surgery patients than the recommended practice of at least 10 days. Extended-duration thromboprophylaxis may require risk stratification to identify high-risk patients. Current risk-assessment models have limitations and are not specific to orthopedic surgery patients; therefore, improvements may facilitate the use of extended-duration thromboprophylaxis in high-risk patients, thereby reducing the burden of venous thromboembolism.

Aftercare↗
PubMed1999

Frostbite: an orthopedic perspective.

Frostbite injury to the extremities has the potential for disastrous effects. This review provides information valuable to the orthopedic surgeon to aid in the evaluation and treatment of frostbite. The pathophysiology and predisposing factors that provide a basic understanding of the nature of frostbite are discussed. Accepted and experimental imaging studies and treatment options are also reviewed. An effort is made to give the orthopedic perspective on each issue, providing a valuable resource for all orthopedic surgeons involved in the care of the patient with frostbite.

Combined Modality Therapy↗
PubMed1996

Centers of excellence: an assessment tool for cardiovascular and orthopedic programs.

As payers place more weight on contracting with hospital/health system programs that can differentiate themselves in the market as a "true" center of excellence (COE), it becomes imperative that hospitals/health systems understand the payer perspective about those programmatic attributes that can truly differentiate them from other programs. This report describes an evaluation and rating methodology for hospital/health system subspecialty programs, particularly cardiovascular and orthopedic programs, that can be used as a self-assessment tool. Using as its core a Rating Scale and Ranking Taxonomy, the evaluation and rating methodology presented here allow cardiovascular and orthopedic programs to do the following: Understand the differentiating characteristic of COE. Rate itself against detailed criteria that are being used by payers. Compare aspects of its program to premier or benchmark programs. Interpret the results to assist with strategic and operational direction. Allocate scarce resources to implement a subspecialty program that will attract payers. The Rating Scale and Ranking Taxonomy has 20 criteria for assessing cardiovascular programs and 18 criteria for orthopedic programs. The assessment process is designed to produce two important results: dialogue and action. The underpinnings of any action is a solid business plan that clarifies the program's vision, values, and mission. They are important because most programs will ultimately pursue very similar strategies and tactics; however, the most successful subspecialty programs and practices will be the ones that can execute the strategies and tactics quickly and effectively. In addition, the changes that are engendered by this targeted yet comprehensive assessment process can lead to improved clinical and functional outcomes for patients, as well as systemic improvements in the delivery of care.

American Hospital Association↗
PubMed1999

Effect of perioperative prophylactic antimicrobial treatment in dogs undergoing elective orthopedic surgery.

OBJECTIVE: To determine whether perioperative antimicrobial prophylaxis would reduce incidence of postoperative infection among dogs undergoing elective orthopedic procedures. DESIGN: Randomized, controlled, blinded, intention clinical trial. ANIMALS: Dogs of any breed, sex, or age undergoing elective orthopedic surgery at a veterinary teaching hospital. PROCEDURES: Dogs were randomly assigned to 1 of 3 groups: treatment with saline solution, treatment with potassium penicillin G, and treatment with cefazolin. Treatments were intended to be administered within 30 minutes prior to surgery; a second dose was administered if surgery lasted > 90 minutes. Dogs were monitored for 10 to 14 days after surgery for evidence of infection. RESULTS: After the first 112 dogs were enrolled in the study, it was found that infection rate for control dogs (5/32 dogs) was significantly higher than the rate for dogs treated with antimicrobials (3/80 dogs). Therefore, no more dogs were enrolled in the study. A total of 126 dogs completed the study. Monte Carlo simulations indicated that compared with dogs that received antimicrobials prophylactically, dogs that received saline solution developed infections significantly more frequently. Difference in efficacy, however, was not observed between the 2 antimicrobial drugs used. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that perioperative antimicrobial prophylaxis decreased postoperative infection rate in dogs undergoing elective orthopedic surgery, compared with infection rate in control dogs. Cefazolin was not more efficacious than potassium penicillin G in these dogs.

Animals↗
PubMed1999

Is the orthopedic generalist moving toward extinction?

Medical students are influenced in their career choice by many factors. By government mandate, 50% of medical students from each graduating class should select primary care as their career choice. Peers and mentors contribute additional influences. The student's personality, preference for living in a rural or urban community, and the possible educational and cultural opportunities for self and/or family in a particular community are also influential factors. The medical student choosing orthopedic surgery as a professional career faces competition; there are four applicants for each residency opening, and the number of orthopedic residents allowed for each program is being reduced. The current belief of policy-makers both outside and within orthopedics is that there are "too many specialists of all kinds." The present article examines the factors that influence the medical student's choice in career selection and shows the present trend of clinical practices.

Adult↗
PubMed1998

[State and prospects of the development of war traumatology and orthopedics].

The article deals with the achievements of the department of military traumatology and orthopedics in treatment of different traumas of the locomotor system, complications of these traumas and with different questions of treatment of orthopedic pathologies. It is shown that organisation of specialized orthopedic-traumatological centers in the system of military forces is necessary.

Afghanistan↗
PubMed2000

Orthopedic medical malpractice: an attorney's perspective.

Orthopedic surgeons are trained to manage problems involving the musculoskeletal system. It would be helpful to identify certain procedures, anatomic areas, or issues related to the physician-patient relationship that could potentially lead to a malpractice lawsuit. Once the problems are identified, steps toward continuing education and physician awareness could be initiated. In this study, we performed a randomized nationwide survey of medical malpractice attorneys to evoke their opinion on these issues. We found that the lumbar spine was the most common anatomic area involved in orthopedic medical malpractice cases, and a physician appearing rushed and uninterested is most likely to be the subject of a lawsuit where a poor physician-patient relationship was a contributing factor. Educational and professional programs are needed to increase the awareness and knowledge of orthopedic malpractice risks, and also to identify potentially preventable problems leading to malpractice litigation.

Adult↗
PubMed2000

Hepatitis C virus infection: review and implications for the orthopedic surgeon.

Hepatitis C virus (HCV), a single-stranded ribonucleic acid virus identified in 1989, is estimated to have infected 1%-2% of the United States population. The incidence of HCV in patients requiring orthopedic surgery may be as high as 5%. Surgeons and operating room personnel are at risk for blood-borne diseases transmitted during surgery. The orthopedic surgeon must be aware of viral infection with this pathogen for the safety of the entire operating room team. Further, screening for HCV is routinely done when a patient donates autologous blood prior to elective surgery, and the orthopedic surgeon is often the first or only physician informed of a positive result. The surgeon should know how to interpret the result, advise the patient, and incorporate the diagnosis of HCV into the plan for the proposed surgery. We will review the natural history, transmission, evaluation of, and current treatment for infection with this blood-borne virus.

Blood Transfusion, Autologous↗
PubMed2001

Clinical experience with epoetin alfa in the management of hemoglobin levels in orthopedic surgery and cancer. Implications for use in gynecologic surgery.

Recombinant human erythropoietin (r-HuEPO, epoetin alfa) is used for treatment of anemia associated with chemotherapy for non-myeloid malignancies, chronic renal failure and zidovudine treatment in patients infected with the human immunodeficiency virus and for anemic patients undergoing elective, noncardiac, nonvascular surgery. Epoetin alfa has been shown to safely increase preoperative hemoglobin (Hb) levels in anemic patients undergoing elective noncardiac, nonvascular surgery and is more effective than preoperative autologous blood donation in reducing the need for perioperative blood transfusions in orthopedic surgery patients. Epoetin alfa was shown to significantly increase Hb levels and decrease transfusion requirements in gynecologic cancer patients undergoing chemotherapy. A once-weekly regimen of 40,000 IU per dose was effective in these patients. In addition to decreasing transfusion requirements and increasing Hb, epoetin alfa for relieving anemia-related fatigue and improving quality of life was demonstrated in clinical trials in anemic cancer patients receiving chemotherapy. With regard to quality of life in orthopedic surgery patients, a novel instrument to measure the effect of Hb management on postoperative recuperative power (i.e., vigor, functional ability) has been validated and may prove to be useful in optimizing rehabilitation and discharge planning. Extensive clinical experience with epoetin alfa in anemic patients undergoing major elective orthopedic surgery or those with gynecologic cancer provides a strong basis for its use in gynecologic surgery.

Anemia↗
PubMed2002

Phylogenetic analysis indicates transmission of hepatitis C virus from an infected orthopedic surgeon to a patient.

During recent years, a controversial discussion has emerged in the medical community on the real number and possible public health implications of hepatitis C virus (HCV) transmissions from infected medical staff to susceptible patients. We report here on molecular virological and epidemiological analyses involving 229 patients who underwent exposure-prone operations by an HCV-infected orthopedic surgeon. Of the 229 individuals affected, 207 could be tested. Three were positive for HCV antibodies. Molecular and epidemiological investigation revealed that two of them were not infected by the surgeon. The third patient, a 50-year-old man, underwent complicated total hip arthroplasty with trochanteric osteotomy. He harbored an HCV 2b isolate that in phylogenetic analysis of the hypervariable region 1 (HVR 1) was closely related to the HCV strain recovered from the infected surgeon, indicating that HCV-provider-to-patient transmission occurred intraoperatively. To our knowledge, this is the first documented case of HCV transmission by an orthopedic surgeon. The recorded transmission rate of 0.48% (95% confidence interval: 0.09-2.68%) was within the same range reported previously for the spread of hepatitis B virus during orthopedic procedures. Since the result of our investigation sustains the notion that patients may contract HCV from infected health-care workers during exposure-prone procedures, a series of further retrospective exercises is needed to assess more precisely the risk of HCV provider-to-patient transmission and to delineate from these studies recommendations for the guidance and management of HCV-infected medical personnel.

Base Sequence↗
PubMed2001

The orthopedic patient's special need for wholistic caring.

The care of patients with musculoskeletal and subsequent orthopedic injuries is a challenging one for the nurse. Wholistic care involves much more than physical care although this is, in itself, a challenge. Care by staff, family, and friends who respond to the patient with orthopedic injuries must include attention to the complex adjustments that the patient is making psychologically to both present and future disabilities. The author's personal experience as an orthopedic patient was the impetus for this article.

Delivery of Health Care↗
PubMed2002

Anticoagulant effect at the time of epidural catheter removal in patients receiving twice-daily or once-daily low-molecular-weight heparin and continuous epidural analgesia after orthopedic surgery.

In patients who receive co-administered low-molecular-weight heparin (LMWH) and continuous epidural analgesia (CEA) after orthopedic surgery, there is concern about an increased risk of a spinal epidural hematoma. The practice of twice-daily LMWH dosing in North America might, in part, account for the greater number of epidural hematomas reports compared to Europe where once-daily LMWH is used. We performed a prospective cohort study in patients who had orthopedic surgery and received co-administered LMWH and CEA. We investigated the trough anticoagulant effect, as measured by an anti-Xa heparin level, at the time of epidural catheter removal in patients who received twice-daily or once-daily LMWH. Twenty-five patients who received enoxaparin, 30 mg twice-daily, and 25 patients who received dalteparin, 5,000 IU once-daily, had anti-Xa heparin levels measured on the second or third post-operative day at the time of epidural catheter removal. In patients who received twice-daily enoxaparin, or once-daily dalteparin, the anti-Xa heparin level was measured, on average, 10.4 h and 21.8 h, respectively, after the preceding LWMH dose. All 25 patients who received once-daily LMWH had an anti-Xa heparin level < 0.10 U/ml at the time of catheter removal. Of 25 patients who received twice-daily LMWH, the anti-Xa heparin level at the time of catheter removal was > or = 0.20 U/ml in 5 patients (P = 0.050), and > or = 0.10 U/ml in 7 patients (P = 0.009). We conclude that in patients who are receiving co-administered LMWH and CEA after orthopedic surgery, twice-daily but not once-daily LMWH administration is more likely to be associated with a clinically important anticoagulant effect at the time of epidural catheter removal.

Aged↗