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PubMed2002

Thrombosis prophylaxis in orthopedic surgery: current clinical considerations.

Thrombosis prophylaxis in orthopedic surgery is an important consideration in order to avoid the morbidity and mortality of venous thromboembolism (VTE). Patients who do not receive prophylaxis, or receive inadequate prophylaxis, may be at risk for clinical or fatal pulmonary emboli, and a fatality, although rare, may be the first sign of a VTE. Although the surgeon may have corrected the patient's orthopedic problem, a symptomatic or asymptomatic venous thrombosis may become a new threat to the patient's quality of life. This problem places such patients at risk for recurrent VTE, as well as post-thrombotic syndrome, a progressive, lifelong disability. Methods of prophylaxis that prevent the most clots result in the fewest venous thromboembolic events, but no one method of prophylaxis is suitable for all patients. In order to select the appropriate modality, a careful risk assessment of each patient is necessary. Those at low or moderate risk levels do not require the same modalities that may be used in a patient with a previous history of thrombosis or with many risk factors. The purpose of this brief review is to examine the complications associated with venous thromboembolism and to discuss, in detail, the risk of thrombosis in orthopedic patients. In addition, thrombosis prophylaxis modalities are discussed and suggestions made based on current Chest Consensus Guidelines and FDA-approved products.

Humans↗
PubMed1976

[Basic documentation by nonmedical personnel in an Orthopedic University Hospital (author's transl)].

A report was presented concerning the experience with the basic documentation of stationary and ambulatory patients in an orthopedic hospital for which the diagnostic code and the orthopedic-surgical code from the Commission for "Orthopedic Documentation" of the DGOT proved successful. It was particularly interesting to note that the same results were obtained by nonmedical personnel on the basic documentation as by interns and residents.

Allied Health Personnel↗
PubMed2003

[Allogeneic blood transfusion policy in orthopedic surgery].

OBJECTIVES: This retrospective study was performed to evaluate transfusions in orthopedic surgery and, in the light of our successful practice, to contribute to the development of appropriate transfusion policies in Turkey. METHODS: In this study 1,811 female patients who underwent orthopedic elective or emergency surgery from January 1997 to December 1999 (group 1) and from January 2000 to December 2002 (group 2) were retrospectively evaluated with respect to ordered and transfused blood units. Autologous blood transfusions were not included. Group 1 consisted of 990 patients (mean age 50.4 years); group 2 consisted of 821 patients (mean age 53.3 years). Maximum surgical blood order schedule (MSBOS) ratios and preference for red blood cell transfusions were determined. Perioperative target hemoglobin level was 10 gr /dL in both groups. In group 2, allogeneic blood transfusions were performed according to the principles established in January 2000, which aimed (i) to more precisely estimate blood loss during surgical procedures and to prevent inappropriate use of blood products; (ii) to reduce the frequency of "standard one unit transfusion" through administration of crystalloids and colloids to the extent of complete elimination of transfusions; and (iii) to use blood components (erythrocyte suspensions) instead of whole blood. RESULTS: In both groups, the MSBOS ratios were below 2, being 1.83 in group 1, and 1.59 in group 2. The medians of requested and transfused blood units were 2 and 1 in group 1, and 3 and 2 in group 2, respectively, resulting in statistically significant differences (p<0.05). The "standard one unit transfusion" rate was 28.7% in group 1, and 18.9% in group 2. Preferences for red blood cell transfusions showed statistically significant increases over the consecutive years. The use of erythrocyte suspensions was found as 29.2% in group 1, and 95% in group 2. CONCLUSION: Our data demonstrated that the transfusion policy established for orthopedic surgical procedures at our center resulted in successful applications thanks to a good cooperation between relevant departments and achieved the level of international standards.

Blood Loss, Surgical↗
PubMed2003

Venting during prophylactic nailing for femoral metastases: current orthopedic practice.

INTRODUCTION: Reamed intramedullary nailing, recommended for impending fracture of a femur weakened by bone metastases, causes a rise in intramedullary pressure and increases the risk of a fat embolism syndrome. The pressure can be equalized by the technique of venting--drilling a hole into the distal cortex of the femur. Our objective was to study the current practice of orthopedic surgeons in Ontario with respect to venting during prophylactic intramedullary nailing for an impending femoral fracture due to bone metastases. METHODS: We mailed a questionnaire to all orthopedic surgeons from the Province of Ontario listed in the 1999 Canadian Medical Directory or on the Canadian Orthopaedic Association membership list, asking if they vent when prophylactically nailing an impending pathologic femoral fracture. The responses were modelled as a function of surgeon volume and year of graduation. RESULTS: Of the 415 surveys mailed, 223 (54%) surgeons responded. Of these, 81% reported having prophylactically treated a femoral metastatic lesion during the previous year; 67% treated 1 to 3 metastatic lesions and 14% treated more than 3; 19% did not treat a metastatic femoral lesion prophylactically. Over two-thirds of surgeons had never considered venting, whereas one-third always or sometimes vented the femoral canal. More recent graduates were 3 times more likely to vent than earlier (before 1980) graduates (odds ratio [OR] = 3.2, 95% confidence interval [CI] 1.6-6.5) as were those who treat a greater number of impending fractures (OR = 1.4, 95% CI 1.1-1.7). CONCLUSIONS: Although there is a theoretical rationale for routine venting, there is disagreement among Ontario orthopedic surgeons regarding the use of this technique during prophylactic nailing for femoral metastatic lesions. Prospective evidence will be required to warrant a change in the standard of care.

Attitude of Health Personnel↗
PubMed2003

[Prevention of venous thromboembolism after major orthopedic surgery: update and contribution of a specific synthetic inhibitor of factor Xa].

Despite widespread use of antithrombotic agents, major orthopedic surgery (total hip arthroplasty, major knee surgery, fracture of the femoral neck) still raises a high risk of deep vein thrombosis and pulmonary embolism. Proper understanding of thromboprophylaxis in orthopedic surgery requires good knowledge of the mechanisms of coagulation and the point of action of different antithrombotic agents. Sodium fondaparinux is the first synthetic inhibitor selective for factor Xa. It is composed of five saccharide units obtained by chemical synthesis, thus eliminating the risk of contamination by a pathogenic agent of animal origin and batch variability. Clinical trials using sodium fondaparinux for the prevention of venous thromboembolism after major orthopedic surgery have demonstrated its superiority over low-molecular-weight heparin without increased risk of clinically pertinent bleeding if the first injection is given at the proper time. We present the main results of clinical trials.

Clinical Trials as Topic↗
PubMed2004

Prevention of deep vein thrombosis in orthopedic surgery.

In the absence of thromboprophylaxis, venous thromboembolism (VTE) affects about 50 to 80% of the patients after total hip replacement (THR), total knee replacement (TKR), or hip fracture surgery. Since stratification of patients in those who will become symptomatic and those who will not, is not possible, primary high risk thromboprophylaxis should be provided to all patients undergoing major orthopedic surgery of the lower extremity. Various non-pharmacologic and pharmacologic thromboprophylactic measures have been evaluated. With regard to pharmacologic thromboprophylaxis unfractionated heparin has now almost completely been replaced by low molecular weight heparin (LMWH) for VTE prophylaxis. The use of acetylsalicylic acid for thromboprophylaxis in patients undergoing major orthopedic surgery of the lower extremities is not recommended. The optimal beginning of LMWH thromboprophylaxis is either 2 hours preoperatively or 6 to 8 hours postoperatively. Extended thromboprophylaxis (beyond 7 to 10 days after surgery) is recommended for high-risk patients. New antithrombotics, such as fondaparinux or (xi)melagatran, significantly reduce the risk of asymptomatic but not of symptomatic VTE compared to LMWH. In the light of other potential side effects (e.g., an increased bleeding risk) and high costs the role of these new drugs in the prophylaxis of VTE in patients undergoing major orthopedic surgery of the lower extremities remains to be established.

Anticoagulants↗
PubMed2004

[The reasons for postponement of scheduled orthopedic surgical operations and its effect on the patients' anxiety and pain levels].

OBJECTIVES: This comparative-descriptive study was planned to evaluate the reasons for postponement of scheduled orthopedic surgical operations and its effect on anxiety and pain levels of patients. METHODS: The study included 100 patients (age range 21 to 56 years) who were admitted to the orthopedics department for a scheduled surgical operation in the lower extremity. Fifty patients who were subject to postponement of the operation on the scheduled day comprised the study group, and 50 patients who underwent surgery on the intended day comprised the controls. Data were collected by means of a patient questionnaire, the Spielberger State and Trait Anxiety scale, and a pain assessment scale. Evaluation of pain was made six times at regular intervals within 48 hours postoperatively. The results were compared. RESULTS: The most common reason (28%) for postponement was the presence of medical diseases on the part of the patient. Most frequently, the decision for postponement came from anesthesiologists (42%). Compared to the preoperative level, the mean state anxiety score showed a significant increase following the notification of the patients concerning the postponement (p=0.001). The number of patients who reported "disturbing pain" was at all times high in the study group, being significantly more in the second, third, and sixth evaluations. CONCLUSION: Postponed surgical operations result in an increased degree of emotional trauma and pain in patients assigned to have orthopedic surgical interventions.

Adult↗
PubMed2005

The pattern of orthopedic admissions in Tikur Anbessa University Hospital, Addis Ababa.

A one-year (April 1st 2003-March 31st 2004) prospective descriptive study of orthopedic admissions to Tikur Anbessa University Hospital (TAUH) was made in order to determine the burden of musculoskeletal conditions together with the present provision of care. A total of 824 patients were admitted of whom 576 were males and 248 females (M:F 2.3:1). The median age was 15 years (range 3 months to 80 years). Trauma was the cause for admission in 507 (61.5%), with road traffic accidents accounting for 211 (41.6%) and a fall for 195 (38.5%). 'Elective' patients waited for an average of 33.5 days for their admission. The mean duration of stay in hospital between admission and elective operation was 11.7 days. The post-operative stay was 20.6 days and the average length of hospital stay of all patients admitted was 35.4 days. The bed occupancy rate was 97.4% with an average time between the discharge of one patient and the admission of another (turnover interval) of 24 hours. Eighty-seven percent of the patients (97/112) who had previously visited a traditional healer presented with a chronic infection, a neglected or a complicated fracture or an advanced tumor. Eleven patients died (1.4%). Health education in the community and of traditional healers, together with a reduction of road traffic accidents would significantly reduce morbidity and mortality in Ethiopia. Major attempts must be made to reduce both the length of time patients wait for elective surgery after being admitted and their post-operative stay in order to serve more people. But it is vital to continue to teach conservative management of fractures as these will be the only methods available for the foreseeable future in hospital outside the centers of excellence. A series of specific recommendation are made to improve our care of orthopedic and trauma patients. We also suggest a broad based community study with an orthopedic input, which would help to produce a better profile and sound decisions to enable this to be achieved.

Adolescent↗
PubMed2006

Effect of oral ketamine on the postoperative pain and analgesic requirement following orthopedic surgery.

BACKGROUND: Ketamine is a potent analgesic agent in addition to its anesthetic properties. Oral ketamine has been used to treat postoperative stump pain following lower limb amputation. In this study, oral ketamine was used to reduce the severity of postoperative pain following orthopedic surgery. METHODS: Seventy-two adult traumatic patients undergoing orthopedic operations were randomly divided into ketamine and placebo groups. In ketamine group, oral ketamine administered at 8-hour intervals postoperatively. Severity of postoperative pain, amount of morphine used, and the time to first rescue analgesic were determined and compared between two groups. RESULTS: Patients in ketamine group had significantly lower scores of postoperative pain (5.2 +/- 1.2, 4.9 +/- 1.6, 4.4 +/- 2.2, 4.3 +/- 1.5, and 3.4 +/- 1.3 at 2, 4, 8, 16, and 24 h postoperatively vs. 7.7 +/- 1.5, 7.3 +/- 1.6, 6.3 +/- 1.9, 6.0 +/- 1.6, and 5.1 +/- 1.8 in placebo group; P < 0.05). The amount of morphine required in the first postoperative day was significantly lower in ketamine group (10.1 +/- 5.6 mg vs. 13.4 +/- 7.8 mg in placebo group; P < 0.05). Time to first rescue analgesic in the ward was significantly longer in ketamine group (3.5 +/- 1.5 h vs. 1.9 +/- 1.2 h in placebo group; P < 0.05). A female patient in ketamine group developed postoperative emergence reaction following extubation. CONCLUSIONS: Oral ketamine may be used to reduce postoperative pain following orthopedic procedures in the traumatic patients. Since only one patient developed psychological side effect (which we can not attribute to ketamine with certainty) it can be concluded that oral ketamine is not so fearsome with respect to emergence reaction.

Administration, Oral↗
PubMed1990

The relationship of physician assistants to an orthopedic residency program.

In 1979, coincident with a planned decrease in the size of the general surgery training program, the orthopedic department of the senior author's university-affiliated teaching hospital began to employ physician assistants. The intent of using physician assistants was to relieve the two orthopedic residents assigned to the hospital of many service responsibilities and patient care that previously had been rendered by the general surgical residents and interns. The non-M.D. physician assistants record a comprehensive past and present medical history, carry out physical exams, and assist at surgery. They are directly under the supervision of and responsible to the attending surgeon. It was hoped the addition of these individuals will help maintain a quality educational experience for the orthopedic residents. The general response to the use of physician assistants in this affiliated hospital has been favorable.

Hospital Bed Capacity, 300 to 499↗
PubMed1991

Ambulatory surgery and prepared discharges. Effects on orthopedic patients and nursing practice.

Orthopedic medical and nursing practice has changed dramatically partly as a result of three trends: cost containment, technology, and consumer activism. Many orthopedic procedures previously requiring inpatient hospital stays are routinely performed on an outpatient, day-surgery basis. it is imperative that nurses working in the ambulatory surgery environment be diligent in practicing the nursing process to ensure comprehensive patient care. Patients requiring hospitalization for orthopedic procedures now have shorter lengths of stay. The brevity of stay means that a great deal of coordination, education, and referral efforts are necessary before the patient's discharge. Prepared discharge programs, with the nurse assuming the coordinator role, are one way of ensuring that patients are ready to make the transition from the hospital to their postdischarge environment.

Ambulatory Surgical Procedures↗
PubMed1988

[Technical orthopedic management of osteopathies in adulthood].

Some indications for orthopedic appliances in the treatment of bone disease in adult patients are discussed. The fit of an appliance and comfort in use are important factors in its acceptance, as are the duration of use required and the standard of maintenance available for it. The role of orthopedic appliances in the rehabilitation of adult orthopedic patients is discussed with reference to osteogenesis imperfecta. The provision of individually adapted chair seats or extension of the patients' area of activity by means of special wheel-chairs are possible ways of improving their quality of life and, indirectly, that of their families.

Adult↗
PubMed1986

[Technical orthopedic aspects of the treatment of arthroses].

Technical orthopedic treatment of joint diseases still has a place in the treatment plan, although the role is supplementary and it is seldom the only form of therapy. Its most important tasks have to do with immobilization and stabilization, followed by shock absorption, decompression, and equalizing defective axial positioning and differences in leg length. Finally, orthopedic treatment plays an important role in joint diseases in the protection of the joint from cold and drafts. Deformed joints, malpositioning, atrophied soft tissue and poor circulation, however, require that the indications be weighted carefully. The various technical orthopedic possibilities are presented and discussed.

Bone Diseases↗
PubMed1981

Orthopedic patients in an ambulatory surgery facility.

There is no doubt that ambulatory surgical intervention is here to stay. The advantages afforded the patient are substantial. Orthopedic procedures that previously required one to two nights of hospitalization are now routinely performed on an outpatient basis. This is a result of an increase in the use of arthroscopic surgery and an awareness of the importance of preoperative preparation and postoperative follow-up of the patient. Given the usual localized nature of orthopedic problems, the usual pre-existing good health of the orthopedic patient, and his or her desire to return to normal functioning as soon as possible, the scope of what can be accomplished on an ambulatory surgical basis is just beginning to be realized.

Adult↗
PubMed1994

[30 years of operation at the Cathedral and Orthopedic Clinic of the Medical Academy in Lodz].

University Orthopedic Department in Lódź was founded on January 1, 1964. The first head of the Department was prof. E. Bartkowiak M.D., Ph.D. and prof. H. Zwierzchowski M.D., Ph.D. took over in 1979. During past years out of 38 surgeons employed 8 became head of other orthopedic-traumatologic departments. An orthopedic training completed 22 graduates, Ph.D. was received by 20. The Department took part in pre- and post-graduate teaching. 14,570 operations have been performed on 31,091 admitted patients (12,969 children, 18,122 adults). Out Patient Department helped 139,493 persons. The employees published 232 papers, 35 of them abroad. They participated in 21 congresses, meetings and symposia abroad as well as in 15 domestic PTO I TR congresses with 72 presentations and organized two of them in 1966 and 1984. They were also included in General Board of PTO I TR as well as its Lódź branch.

Academic Medical Centers↗
PubMed1994

[Detection of deep vein thrombosis of the limbs by ultrasound in orthopedic and traumatologic surgery. Results of 1647 studied patients].

INTRODUCTION: This study was undertaken to estimate the efficiency of duplex ultrasound scanning and its utility to detect deep vein thrombosis in orthopedic patients and to describe their features. MATERIAL AND METHODS: A total of 1647 in-patients, all receiving low-molecular-weight heparin, were investigated from 1989 to 1993, either for screening because of a high risk of thrombosis (asymptomatic group: 930 patients, mean age + SD: 63 + 17 years) or for clinical suspicion of deep vein thrombosis (symptomatic group: 717 patients, mean age + SD: 57 + 21 years). Difference between the two groups mean ages was significant (p < 10(-8)). An Hitachi EUB 450 duplex and an Acuson colour duplex 128 XP, with 3.5 MHz and 7.5 MHz linear probes were used. Veins were tested for compressibility in the transverse view from caval site to both ankles. Retrospective analysis of patients' database results was done. RESULTS: There was no significant difference in deep vein thrombosis rate between screening asymptomatic group (356/930: 38 per cent) and symptomatic group (2531717: 35 per cent). There was a linear relation, in the 2 groups, between age and deep vein thrombosis rate, from 10 per cent before twenty to 45 per cent after eighty years old. For a relative risk to have thrombosis detected before twenty definite at 1, it was 2.1 for 20-29, 4.9 for 40-49, 6.2 for 60-69 and 8.6 later than 80 years old. Proximal deep vein thrombosis was detected in only 5 per cent (87/1647) of patients. Distal muscular soleal veins were the most usual involved sites of thrombosis. Isolated soleal thrombosis were detected in 16 per cent (270/1647) of patients. There was no significant difference between the deep vein thrombosis rate after total knee or hip arthroplasty among selected patients for duplex scanning from 1989, and the true prevalence assessed among all the patients who have undergone total hip or knee arthroplasty during the last 6 months. DISCUSSION: Pessimistic results previously reported for duplex screening among asymptomatic patients are not confirmed. Calf vein thrombosis rate assessed with duplex exceeds by 15 to 20 per cent the rates assessed by contrast venography, among patients receiving low molecular weight heparins. That difference could be attributed to the isolated muscular soleal thrombosis usually missed at contrast venography. CONCLUSION: Deep vein thrombosis rate among orthopedic surgical patients, is much higher when detected with Duplex ultrasound scanning than detected with contrast venography, and is related to patient age. Soleal vein thrombosis is the most prevalent. Duplex ultrasound scanning is an efficient and useful screening method for deep vein thrombosis in orthopedic surgery. Mechanical calf venous pump stimulation in association with low molecular weight heparin, has to be evaluated in attempting to reduce those muscular soleal veins thrombosis.

Adult↗
PubMed1994

[Echo-Doppler for early diagnosis of deep venous thrombosis in orthopedic surgery and traumatology. A retrospective study of 1,647 patients].

UNLABELLED: The authors report the results of duplex ultrasound scanning investigation for the detection of deep venous thrombosis after orthopedic surgery and compare asymptomatic and symptomatic populations. PURPOSE OF THE STUDY: To estimate the rate of deep venous thrombosis diagnosed by duplex scanning in those 2 populations and precise their features. MATERIAL: A total of 1,647 in-patients all receiving low-molecular-weight heparin and investigated from 1989 to 1993. either for screening because of high risk of thrombosis (asymptomatic group: 930 patients, mean age +/- SD 63 +/- 17 years) or for clinical suspicion of deep vein thrombosis (symptomatic group; 717 patients, mean age +/- SD: 57 +/- 21 years). Difference between the two groups mean ages were significant (p < 10(-8). METHODS: An Hitachi EUB 450 duplex and an Acuson colour duplex 128 XP, with 3.5 MHz and 7.5 MHz linear probes were used. Veins were tested for compressibility in transverse view from caval site to both ankles. Retrospective analysis of patients database results has been achieved. RESULTS: There was no significant difference in deep vein thrombosis rate between screening asymptomatic group (356/930:38%) and symptomatic group (253/717: 35%). There was a linear relation, in the 2 groups, between age and deep vein thrombosis rate, from 10% before twenty to 45% after eighty years old. For a relative risk to have thrombosis detected before twenty definite at 1, it was 2.1 for 20-29, 4.9 for 40-49, 6.2 for 60-69 and 8.6 later than 80 years old. Proximal deep vein thrombosis was detected in only 5% (87/1,647) of patients. Distal muscular soleal veins were the most usual involved sites of thrombosis. Isolated soleal thrombosis were detected in 16% (270/1,647) of patients. There was non significant difference between the deep vein thrombosis rate after total knee or hip arthroplasty among selected patients for duplex scanning from 1989, and the true prevalence assessed among all the patients who have undergone total hip or knee arthroplaty during the last 6 months. DISCUSSION: Pessimistic results previously reported for duplex screening among asymptomatic patients are not confirmed. Calf vein thrombosis rate assessed by duplex scanning exceeds by 15 a 20% usual rates assessed by contrast venography, among patients receiving low-molecular-weight heparins. That difference could be assigned to the isolated muscular soleal thrombosis usually missed at contrast venography. CONCLUSION: Deep vein thrombosis rate among orthopedic surgical patients, is much higher when detected with Duplex ultrasound scanning than detected with contrast venography, and is related to patient age. Screening for deep venous thrombosis by duplex scanning in orthopedic surgery is as efficient among asymptomatic as among symptomatic patients and could become soon a systematic screening. Soleal vein thrombosis are the most usual. Mechanical calf venous pump stimulation in association with low molecular weight heparin, has to be evaluated in attempting to reduce those muscular soleal veins thrombosis.

Aged↗
PubMed1995

Variation in orthopedic surgeons' perceptions of the indications for and outcomes of knee replacement.

OBJECTIVE: To determine the agreement among orthopedic surgeons' indications for knee replacement, their perceptions of the usefulness of various treatments for osteoarthritis of the knee and their expected outcomes of knee replacement, and to determine the relation between these opinions and the number of knee replacement procedures performed by individual surgeons. DESIGN: Survey. SETTING: Ontario. PARTICIPANTS: All 392 orthopedic surgeons in the province. Of the 325 practising traceable surgeons 234 (72.0%) responded. OUTCOME MEASURES: Indications for knee replacement, perceived usefulness of treatments for osteoarthritis, perceived outcomes of knee replacement and number of knee replacement procedures performed by individual surgeons. RESULTS: The respondents disagreed on how 20 of 34 patient characteristics affected their decision to perform knee replacement surgery. They also disagreed on the usefulness of seven of eight treatments for arthritis of the knee. The respondents demonstrated variation in their expected outcomes of knee replacement. The surgeons who performed more procedures judged, on average, the outcomes to be better and to have fewer complications than the surgeons who performed fewer procedures. CONCLUSIONS: Orthopedic surgeons demonstrated disagreement about some of the indications for knee replacement, the usefulness of treatments for arthritis of the knee and the perceived outcomes of knee replacement. The areas of greatest disagreement should be the focus of future research and the development of practice guidelines.

Adult↗