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PubMed2000

Injectable biodegradable materials for orthopedic tissue engineering.

The large number of orthopedic procedures performed each year, including many performed arthroscopically, have led to great interest in injectable biodegradable materials for regeneration of bone and cartilage. A variety of materials have been developed for these applications, including ceramics, naturally derived substances and synthetic polymers. These materials demonstrate overall biocompatibility and appropriate mechanical properties, as well as promote tissue formation, thus providing an important step towards minimally invasive orthopedic procedures. This review provides a comparison of these materials based on mechanical properties, biocompatibility and regeneration efficacy. Advantages and disadvantages of each material are explained and design criteria for injectable biodegradable systems are provided.

Animals↗
PubMed1995

Client counseling in orthopedic emergencies.

Important client communication issues associated with most orthopedic emergencies are addressed. Information on client communication and support, providing a prognosis, discussing economic concerns, discharge planning, euthanasia, and client grief is presented. The issue of animal abuse as a cause of orthopedic emergencies also is examined.

Animal Welfare↗
PubMed2002

Making your orthopedic office profitable through the addition of ancillary services.

With the precipitous decline of orthopedic reimbursement over the past six years, it will be critical to the success of the majority of orthopedic groups to improve their revenue stream in the future. This will involve improving management, reducing overhead, and adding ancillary services to obtain facility fee revenue. Ancillary service possibilities for the orthopedist include an in-office surgicenter with a pain center, MRI, physical therapy with orthotics and braces, occupational health department, pharmacy, and independent medical examination company.

Ambulatory Care Facilities↗
PubMedDate not supplied

Orthopedic implants: a guide to radiographic analysis.

Orthopedic technology is growing at a rapid rate. New implants reflect this technology whether it pertains to fracture fixation, joint replacement, spine stabilization, or soft-tissue reconstruction. This monograph is designed to assist both the radiologist and the orthopedist in accurately assessing plain radiographs of commonly used orthopedic implants. We discuss the biologic response of the surrounding bone to these devices; herein lies the key to understanding the radiographic presentation of these devices.

Arthritis↗
PubMed2003

Evaluation and management of the high-risk orthopedic emergency.

Orthopedic injuries are frequently seen in the ED. Whereas the diagnosis and management of most of these injuries is straightforward, there are distinct pitfalls to avoid. The common theme among the high-risk "pitfall" injuries discussed in this article, besides a thorough patient history and careful physical examination with appropriate radiographs, is a high suspicion for the presence of these injuries. When the EP is knowledgeable about these orthopedic pitfalls, these injuries are much less likely to slip by in clinical practice.

Adult↗
PubMed2003

Critical care in orthopedic and spine surgery.

Complications of orthopedic and spine operations can be life threatening. Proper patient selection, careful planning of patient care, and prophylactic measures are important determinants of a successful outcome. After elective orthopedic surgery such as total joint replacement, the intensivist should be aware of potential systemic complications common to any major surgical intervention (pneumonia, pulmonary embolism, sepsis, myocardial infarction) and also of procedure-specific problems (cement-related cardiac events, fat embolism) and local complications (neurovascular injuries). Patients undergoing spine procedures should have close neurologic monitoring for immediate and delayed deficits.

Anesthesia, General↗
PubMed2000

Bedside orthopedic procedures.

Orthopedic bedside procedures commonly are performed and are appropriate. As the complexity of patient needs increases and resources are stretched, more patient care, including orthopedic procedures, will be performed in cost-effective but safe environments such as the monitored intensive care setting. Medical technology and expertise are expanding rapidly, and these improved resources can and will allow more procedures to be performed safely and effectively outside the operating room. The decision to perform a specific procedure on a specific patient in a specific environment requires careful consideration of the risk to benefit ratio. This consideration should involve the patient, the physicians, and the entire health care team.

Adult↗
PubMed1996

Decision making in ruminant orthopedics.

Decision making in ruminant orthopedics is determined by many factors, the most of important of which is age, size, and value of the patient, the nature of the injury, the prognosis for effective treatment and satisfactory healing, the intentions of the client, and the experiences of the veterinarian. Ruminant orthopedics currently is expanding to include the treatment of llamas and small ruminants as companion animals in addition to the treatment of valuable livestock. The future promises increasing sophistication in treatments and an ever higher quality of patient care.

Animals↗
PubMed1996

Instrumentation and techniques for treating orthopedic infections in horses.

Orthopedic infections-those involving bones, joints, tendon sheaths, or bursae-are some of the most difficult problems for equine surgeons to treat successfully. Sources of the infection are usually hematogenous, traumatic, or iatrogenic and knowledge of the most likely causative bacteria is very useful in selecting the most appropriate antimicrobial(s) to either prevent or treat these infections in horses. This article discusses the clinical findings, diagnosis, treatment, and prevention of orthopedic infections in horses. More recent treatment methods such as synovial drainage techniques (arthroscopy and arthrotomy), intrasynovial antimicrobials, regional perfusion of antimicrobials, and antimicrobial-impregnated polymethylmethacrylate (PMMA) beads or cylinders are also addressed.

Animals↗
PubMed2001

Propofol and remifentanil pharmacodynamic interaction during orthopedic surgical procedures as measured by effects on bispectral index.

STUDY OBJECTIVE: To identify and quantify the interaction between propofol and remifentanil during surgical procedures with a bispectral index (BIS) of 50 that was chosen as a continuous surrogate measure for "adequate depth" of anesthesia. DESIGN: Prospective, open-label study. SETTING: Department of orthopedics of a university hospital. PATIENTS: 20 patients undergoing orthopedic surgery. INTERVENTIONS: Anesthesia was induced and maintained with propofol and remifentanil, both administered by target-controlled infusion (TCI). Initial target concentrations of propofol (1.5-8 microg/mL) and remifentanil (2-15 ng/mL) were chosen and alternated in order to maintain the BIS between 45 and 55. If constant target concentrations had been maintained for 20 minutes and the BIS did not depart from the desired range, blood samples were taken to determine propofol concentrations, and the BIS value was recorded. Isobolographic interaction models were fitted to the infusion rates of remifentanil and propofol, predicted target concentrations of both drugs, and measured propofol concentrations versus predicted remifentanil concentrations. MAIN RESULTS: The isobole for the interaction of propofol and remifentanil in the concentration range investigated (propofol 1.5-8 microg/mL and remifentanil 1-30 ng/mL) is a concave up hyperbola ((0.15. C(prop))(3.13). C(rem) = 1) with C(prop) = propofol plasma concentration [microg/mL] and C(rem) = remifentanil blood concentration [ng/mL]). Use of predicted (=TCI target) concentrations or the respective infusion rates did not alter the general shape of the interaction isobole. CONCLUSIONS: The interaction between propofol and remifentanil for maintenance of a BIS value between 45 and 55 during surgery is synergistic. This finding applies regardless of whether measured concentrations (for propofol), predicted concentrations of the infusion device, or infusion rates are used as model input. Notably, the interaction isobole of the (clinically readily available) infusion rates provides a useful dosing recommendation for the coadministration of propofol and remifentanil during maintenance of anesthesia.

Adult↗
PubMed1998

Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery.

STUDY OBJECTIVES: (1) To incorporate regional anesthesia options for common outpatient orthopedic surgery into clinical pathways; (2) to use the clinical pathway format and the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as management tools to measure postoperative same-day surgery processes and discharge outcomes; and (3) to determine the effects of general, regional, and combined general-regional anesthesia on these processes and outcomes. DESIGN: Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathway existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group. SETTING: Ambulatory surgery center in a teaching hospital. MEASUREMENTS AND MAIN RESULTS: The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients selected general anesthesia (+/- femoral nerve block) or epidural anesthesia, after which the remainder of the perioperative anesthesia process was standardized with respect to the drugs and equipment used. 1995-1996 patients did not necessarily have a choice in anesthesia technique and did not have a standardized perioperative anesthetic course with respect to specific drugs and supplies. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by anesthesia technique used, were measured. Combined general-regional anesthesia care for ACLR in 1996-1997, when compared with general anesthesia alone, led to increased pharmacy and materials costs and increased turnover time. However, patients with the combined technique showed improved recovery profiles and lower unexpected admission rates, and they required fewer nursing interventions for common postoperative symptoms. Patients receiving epidural anesthesia showed discharge outcomes similar to those patients receiving general anesthesia with femoral nerve block. Postanesthesia care unit bypass (fast-tracking) was more likely in clinical pathway regional anesthesia patients, when compared with the clinical pathway general anesthesia used. CONCLUSIONS: Clinical pathway regional anesthesia care for outpatient orthopedics may have a significant role in simultaneously containing costs and improving both process efficiency and patient outcomes.

Adult↗
PubMedDate not supplied

Greater trochanteric pain syndrome in patients referred to orthopedic spine specialists.

BACKGROUND CONTEXT: Greater trochanteric pain syndrome (GTPS) is a regional syndrome characterized by pain and reproducible tenderness in the region of the greater trochanter, buttock or lateral thigh that may mimic the symptoms of lumbar nerve root compression. Despite these known features, the diagnosis of GTPS is often missed, and documentation of its prevalence in an orthopedic spine specialty practice is lacking. PURPOSE: To determine the prevalence of the GTPS in patients referred to a tertiary care orthopedic spine referral center for the evaluation of low back pain, and to describe the demographic and clinical characteristics of patients with this syndrome. STUDY DESIGN/SETTING: Retrospective analysis. PATIENT SAMPLE: A total of 247 consecutive patients referred for low back pain from August 1998 through December 2000. OUTCOME MEASURES: Clinical response to injection, demographic characteristics, physical examination findings, prevalence of GTPS and preexisting diagnostic evaluations. METHODS: The diagnosis of GTPS was made based on history and physical examination and was confirmed by response to anesthetic corticosteroid injection. Demographic and clinical characteristics of the study group were evaluated. Follow-up data were available at a mean of 8 weeks postinjection (range, 2 to 48 weeks). RESULTS: The prevalence of GTPS was 20.2% (51 of 252). Mean age (54 years) was the same for patients with (range, 25 to 85 years) and without (range, 17 to 85 years) GTPS. Significantly more women than men had GTPS (p<.03). Of the 51 patients diagnosed with GTPS at initial presentation, 54.9% (28 of 51) had already obtained a magnetic resonance imaging examination (although only 15.7%, ie, 8 of 51, demonstrated objective neurologic findings) and 62.7% (32 of 51) had previously been evaluated by an orthopedist or neurosurgeon; one patient had undergone two lumbar decompressions without clinical improvement before our evaluation. CONCLUSIONS: GTPS accounts for a substantial proportion of patients referred to our center for evaluation of low back pain. Both primary care physicians and specialty surgeons may miss this diagnosis, most common in middle-aged women. Accurate recognition of this problem earlier in the evaluation of patients with low back, buttock or lateral thigh symptoms may dramatically reduce costly patient referrals and diagnostic tests and may prevent unwarranted surgery.

Adult↗
PubMed1999

High-resolution morphometric analysis of human osteoblastic cell adhesion on clinically relevant orthopedic alloys.

Understanding the cellular basis of osteoblastic cell-biomaterial interaction is crucial to the analysis of the mechanism of osseointegration, a requirement of long-term orthopedic implant stability. Clinically, the amount of bone ingrowth is variable, and cellular parameters that influence ingrowth have yet to be clearly determined. In this study, two clinically relevant orthopedic alloys, titanium Ti6A14V (Ti) and cobalt-chrome-molybdenum (CC), were used for a comparative analysis of primary human osteoblastic cell adhesion and spreading, where cell adhesion represents the initial interaction between cellular elements and the biomaterial surface. The kinetic profile of adhesion revealed enhanced cell attachment upon rough Ti surfaces relative to rough CC. Using confocal laser scanning microscopy (CLSM), we observed that, during the first 12 h of contact with the substratum, osteoblastic cells were relatively less spread on rough Ti, whereas cells appeared elongated with multiple cellular extensions on rough CC. Focal adhesion contacts, as indicated by vinculin immunostaining, were distributed throughout the cells adhering to Ti, but were relatively sparse and localized to cellular processes on CC. Furthermore, three-dimensional CLSM reconstruction analysis indicated the presence of vinculin at all membrane-to-surface contact points on both Ti and CC. On Ti, these contact points closely followed the surface contour, whereas, on CC, they were restricted to relative topographic peaks only. Actin cytoskeletal reorganization was prominent in cells cultured on Ti, with stress fibers arranged throughout the cell body, whereas, on CC, actin filaments were sparse and localized primarily to cellular extensions. Because cell attachment mechanisms are likely to influence signal transduction and regulation of gene expression, these early differential responses of osteoblastic cells on Ti and CC may have functional implications on subsequent extracellular matrix mineralization and bone ingrowth at the cell-biomaterial interface.

Biocompatible Materials↗
PubMed2006

The incidence of delirium associated with orthopedic surgery: a meta-analytic review.

BACKGROUND: The aim of this study was to perform a systematic review and meta-analysis of the literature regarding the incidence of delirium following orthopedic surgery. METHODS: Relevant papers were sourced from online databases and gray literature. Included studies used a validated diagnostic method to measure the incidence of delirium in a prospective sample of adult/elderly orthopedic patients. Data were subject to meta-analysis after stratification by type of surgery (elective v. emergency) and inclusion/exclusion of pre-existing cognitive impairment. A funnel plot assessed for publication bias. RESULTS: 26 publications reported an incidence of postoperative delirium of 4-53.3% in hip fracture samples and 3.6-28.3% in elective samples. Significant heterogeneity was evident, and this persisted despite stratification. Hip fracture was associated with a higher risk of delirium than elective surgery both when the cognitively impaired were included in the sample (random effects pooled estimate = 21.7% [95% CI = 14.6-28.8] vs. 12.1% [95% CI = 9.6-14.6]), and when the cognitively impaired were excluded (random effects pooled estimate = 25% [95% CI = 15.7-34.7] vs. 8.8% [95% CI = 4.1-13.6]). The funnel plot showed a deficit of small studies showing low risk and large studies showing high risk. In eight hip fracture studies, the proportion of delirium cases with a preoperative onset ranged from 34 to 92%. CONCLUSIONS: Delirium occurs more commonly with hip fracture than elective surgery, and frequently has a preoperative onset when associated with trauma. Recommendations are made with the aim of standardizing future research in order to further explore and reduce the heterogeneity and possible publication bias observed.

Aged↗
PubMed2004

Bioabsorbable implants: review of clinical experience in orthopedic surgery.

Bioabsorbable implants are widely used in orthopedic surgery today and the worldwide market is expanding rapidly. Despite the popularity of these implants, reports of complications continue to appear in the literature. Although the complications rarely have an adverse affect on long-term outcomes, the reports are too numerous to be mere isolated incidents related to one specific implant. Complications have been reported with most of the commercially available implant materials with varying incidence rates and severities of reactions to the implants. The purpose of this review is to summarize the adverse events that have been reported in clinical trials of bioabsorbable implants in orthopedic surgery.

Absorbable Implants↗
PubMed1992

Identifying elective orthopedic surgical patients transfused with amounts of blood in excess of need: the transfusion trigger revisited.

The discharge hematocrit has been analyzed as a clinical indicator of the transfusion trigger by which to identify patients undergoing elective orthopedic surgery who were transfused with blood in excess of need. The volume of red cells lost by each patient during surgical hospitalization was compared to the volume of red cells transfused. Three clinical indicator levels were considered. Red cell losses of 10, 20, and 30 percent of each patient's baseline red cell volume at admission were considered to be appropriate before subsequent blood transfusion replacement, representing generous, intermediate, or strict clinical indicator levels, respectively. With Level I as a generous clinical indicator, 110 (25%) of 525 patients were transfused in excess of blood needs; by Level II (intermediate) and Level III (strict) criteria, 221 (42%) and 314 (60%) of 525 patients, respectively, were transfused in excess of blood needs. Significant differences were found for transfused patients analyzed by gender (26% of women vs. 13% of men; Level I, p less than 0.001) and preoperative autologous blood donation (25% of autologous blood donors vs. 11% of those who did not donate autologous blood; Level I, p less than 0.001). It can be concluded that the discharge hematocrit and amount of blood lost during hospitalization can be used as clinical indicators with which to identify patients receiving transfusions in excess of needs in the elective surgical setting. With this method, it was found that the transfusion trigger is different for women and for men as well as for autologous blood donors and those who did not donate autologous blood undergoing elective orthopedic surgery [corrected].

Blood Transfusion↗
PubMed2003

The cost-effectiveness of fondaparinux compared with enoxaparin as prophylaxis against thromboembolism following major orthopedic surgery.

BACKGROUND: The selective antithrombotic fondaparinux is more effective than the low-molecular-weight heparin enoxaparin for prevention of venous thromboembolism (deep-vein thrombosis [DVT] or pulmonary embolism) in patients undergoing major orthopedic surgery, but its cost-effectiveness is undetermined. OBJECTIVES: To evaluate the cost-effectiveness of fondaparinux relative to enoxaparin as prophylaxis against venous thromboembolism (VTE) for patients undergoing total hip replacement, total knee replacement or hip fracture surgery in the UK. PATIENTS/METHODS: A decision analysis model was created simulating the impact of fondaparinux and enoxaparin on patient outcomes and costs over various time points up to 5 years following surgery. The main outcome measures were treatment costs per patient and the incidence of clinical VTE and VTE-related deaths. A weighted (combined) cohort reflects the proportion of patients undergoing these procedures in 2000/2001. RESULTS: In the combined cohort, compared with enoxaparin, fondaparinux is expected to produce 20 fewer clinical VTE events and 3.2 fewer VTE-related deaths per 1000 procedures at 5 years. Cost savings at 5 years are pound 27 per patient with fondaparinux (discounted at 6% per year). In each of the three surgical groups, fondaparinux leads to lower expected costs per patient and to a smaller number of VTE events and VTE-related deaths. RESULTS are sensitive to the price difference between fondaparinux and enoxaparin and variation in the rate of late DVT. The analysis is robust to variations in all other key parameters. CONCLUSIONS: Compared with enoxaparin, fondaparinux is more effective and reduces costs to the healthcare system. At current prices, fondaparinux is the recommended strategy in the UK for prophylaxis following major orthopedic surgery.

Anticoagulants↗
PubMed2003

The effects of dehydration on rehabilitation outcomes of elderly orthopedic patients.

OBJECTIVE: To study the effects of dehydration, by using the indices of prerenal azotemia and orthostasis, on the rehabilitation outcomes of elderly orthopedic patients. DESIGN: Prospective, pilot study. SETTING: Regional inpatient rehabilitation center. PARTICIPANTS: A consecutive sample of 39 patients (29 women, 10 men), ranging in age from 58 to 94 years (mean, 78y), of whom 13 had total hip replacements, 12 had total knee replacements, and 14 had hip fractures. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay (LOS), change in the FIM trade mark instrument score, and discharge to home. RESULTS: The mean LOS was significantly longer in the group with prerenal azotemia (n=21, 12.9+/-3.0d, t=2.49, P<.01) than in the nonazotemic group (n=18, 9.4+/-4.6d). LOS was also significantly longer in the orthostatic group (n=18, 13.7+/-3.4d, t=2.94, P<.01) than in the nonorthostatic group (n=21, 9.8+/-3.9d). Two-way analysis of variance showed a statistically significant effect on LOS for both azotemia (F=8.4, P=.006) and orthostasis (F=10.5, P=.003). A statistical interaction existed (F=4.7, P=.038), but it was more pronounced in the absence of both conditions, as opposed to the presence of both. LOS for the group with both azotemia and orthostasis was 13.6+/-2.7 days (n=10, F=4.7, P=.038), in contrast to 7.2+/-2.8 days in the group without either condition (n=10). Of the patients who had neither azotemia nor orthostasis, 100% (n=10) went home; 80% (n=8) of patients who had both conditions went home. Logistic regression analysis, however, did not show a statistically significant correlation between discharge to home and the presence of azotemia, orthostasis, or both. CONCLUSION: Prerenal azotemia and orthostasis are present in a significant number of elderly orthopedic patients and have a major effect on rehabilitation outcomes.

Aged↗