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The standardization of orthopedic hip and knee implants was a collaborative endeavor by material management, orthopedic surgeons, and operating room nursing staff. The key concept was to eliminate paying list price for hip and knee implants and to standardize to one vendor and establish the hospital as the premier center for total joint replacement.
In order to get a better data management of complications in orthopedic surgery and in order to get comparable statistics a standardisation of nomenclature and classification of complications is demanded since 1.1.1997. The Orthopedic University Clinic of Heidelberg started with a register of all early complications of all inpatients. According to a standardized nomenclature all occurred complications the doctors put in the data of complications in a database. These data were controlled, complemented and classified by members of the quality management group. This guideline consists of five parts: catalogue of diagnoses, general and special definitions, classification and an allocation table of diagnoses to grades of severity.
The purpose of this prospective, randomized, double-blind, placebo-controlled clinical study was to determine whether the administration of intravenous ketorolac, coadministered with morphine patient-controlled analgesia (PCA), demonstrates an opioid-sparing effect, provides improved analgesia, and reduces the incidence of opioid-induced side effects in children after orthopedic surgery. The findings of enhanced analgesia with decreased opioid use suggest that coadministration of ketorolac with morphine PCA is beneficial for the treatment of pain in children after orthopedic surgery.
OBJECTIVE: To determine the pharmacologic and physical modalities used by orthopedic surgeons in Canada to prevent venous thromboembolism (deep venous thrombosis and pulmonary embolism) after total hip or knee arthroplasty. DESIGN: Mail survey sent to all members of the Canadian Orthopaedic Association. SETTING: A nation-wide study. METHODS: A total of 828 questionnaires, designed to identify the type and frequency of prophylaxis against venous thromboembolism that were used after hip and knee arthroplasty were mailed to orthopedic surgeons. OUTCOME MEASURES: Demographic data and the frequency and type of thromboprophylaxis. RESULTS: Of the 828 surveys mailed 445 (54%) were returned, and 397 were included in this analysis. Of the respondents, 97% used prophylaxis routinely for patients who undergo total hip or knee arthroplasty. Three of the 397 (0.8%) did not use any method ofprophylaxis. Warfarin was the most common agent used (46%), followed by low-molecular-weight heparin (LMWH) (36%). Combination therapy with both mechanical and pharmacologic methods were used in 39% of patients. Objective screening tests were not frequently performed before discharge. Extended prophylaxis beyond the duration of hospitalization was used by 36% of physicians. CONCLUSION: Prophylaxis for venous thromboembolism with warfarin or LMWH has become standard care after total hip or knee arthroplasty in Canada.
A literature review indicates that the exactness of visual estimation of angles has not adequately been addressed. This study used a series of angles to examine how accurately and consistently practicing orthopedic surgeons were able to visually estimate angles. The data indicate that orthopedic surgeons were able to visually estimate angles to within 10 degrees 93.1% of the time and to within 5 degrees 64.6% of the time. Repeat measurements 6 weeks later were within 5 degrees of the initial responses 82.2% of the time and within 10 degrees of the initial responses 94.5% of the time. The number of years in practice or in training was irrelevant to the validity and reliability of the estimates. Acute angles of 31 degrees or less were consistently overestimated.
OBJECTIVE: To determine if patient satisfaction can be improved by changing patients' expectations of the clinic visit and by decreasing the total time spent in the clinic. DESIGN: A prospective comparative analysis carried out in 4 phases. SETTING: An university-affiliated orthopedic outpatient clinic. PATIENTS: All patients seen in the orthopedic outpatient clinic were eligible. Phase 1 determined the total clinic time required by patient type; phase 2 assessed baseline satisfaction; phase 3 altered patients' expectations; and phase 4 altered patients' expectations and scheduled visits by patient type. INTERVENTION: Patient questionnaires. MAIN OUTCOME MEASURE: Patient satisfaction with time spent in the clinic. RESULTS: Of 708 distributed questionnaires, 622 (88%) were completed (547 totally complete, 75 partially complete). Total time spent in the clinic decreased across phases 2, 3 and 4 (mean 99.2, 94.7 and 85.2 minutes, respectively, but was significantly different only between phases 3 and 4; p = 0.05, Duncan's multiple range test). The percentage of patients who rated their waiting time as "excellent" increased across phases 2, 3 and 4 (14.6%, 18.8% and 31.1%, respectively; p = 0.0004, chi 2 test). CONCLUSION: Patient satisfaction can be improved by altering patient expectations and by decreasing the total time spent in clinic.
To determine the efficacy of rofecoxib in post-orthopedic surgery pain, we conducted a double-blind, randomized, placebo- and active-comparator-controlled, parallel-group trial. Two hundred eighteen patients enrolled. Day 1 patients received placebo, rofecoxib 50 mg, or naproxen sodium 550 mg. Days 2 through 5, the placebo and naproxen sodium groups received placebo, and the rofecoxib group received rofecoxib 25 or 50 mg. Rofecoxib 50 mg was superior to placebo (P < .05) and similar to naproxen sodium for all single-dose measures of pain relief. Days 2 through 5, the rofecoxib 50 mg group used less supplemental narcotic analgesia (P = .005) and reported less pain on global evaluations (P = .041) when compared with the placebo group; the efficacy of rofecoxib 25 mg fell between that of placebo and rofecoxib 50 mg for these endpoints (P < or = .267). Rofecoxib 50 mg once daily effectively treated post-orthopedic surgery pain.
We studied all patients (n = 147) discharged from the orthopedic wards at Kärnsjukhuset, Skövde, during a four week period. Two thirds had been admitted via emergency rooms, were older, used more medicines and had more diagnoses than the elective patients, and they required a great deal of medical resources. 38% of the emergency patients did not require specific orthopedic care. 47% of these were more than 80 years of age, had several diagnoses, and had been in-patients in at least two departments during the past year. There is a need for enhanced cooperation and information between departments in order to better provide care for elderly patients with more than one diagnosis.
In elective orthopedic surgery, as well as in any type of clean operations, it is now advised to administer antibiotic prophylaxis only when extraneous material is implanted (prostheses). Given the most frequent appearance of staphylococcal postoperative infections, in orthopedic surgery the antibiotic used for prophylaxis should be particularly active against these microorganisms. Therefore, the first- (cefazolin) and second-generation (cefuroxime or cefamandole) cephalosporins are usually recommended. Because prosthetic infections are more and more frequently caused by methicillin-resistant staphylococci, the glycopeptides (vancomycin and teicoplanin) are often recommended for prophylaxis and more frequently used in routine practice, at least in hospital environments in which these microorganisms often appear. Indeed, various investigations have demonstrated that a single dose of teicoplanin is equally protective as multiple doses of other antibiotics usually used. Regardless of the type of surgery, perioperative prophylaxis should be administered as an i.v. bolus or as a small infusion. However, for mono- or bilateral knee prosthesis, regional prophylaxis has been suggested in recent years, i.e., antibiotic administration in a vein of the foot or leg being operated. The pharmacokinetic and clinical results of this technique have proved to be quite successful.
Like in other operative disciplines also in orthopedic surgery we can see an icrease of infections with gramnegative bacterial like ps. pyocyanea. Gentamicin is in general very effective against these infections. There are following indications for the use of Gentamicin in orthopedic surgery: 1. Parenteral administration only is indicated if there is no other less toxic antibiotic. If it is used a high dosage is necessary because the bone levels which we investigated were very low. Side effects have to be observed. 2. For local therapy Gentamicin is used in the suction and perfusion system in addition to a systemic therapy with Penicillin, Ampicillin or Cephalosporin. Gentamicin can also be used for the wound perfusion. 3. Added to bone cement Gentamicin should only be taken, when an infected total hip is exchanged or if a hospitalism with ps. pyocyanea is known- The administration of Gentamicin is less indicated : 1. Asthe only antibiotic for parenteral therapy in bone infection. 2. Added to bone cement for a general prophylaxis in all endoprosthetic operations.
Selected orthopedic surgical procedures, such as total joint arthroplasty and spinal instrumentation, have some of the highest perioperative transfusion rates of all surgical procedures. Blood transfusions carry the risk of complications, including the transmission of disease, immunomodulation, and hemolytic and non-hemolytic reactions. Strategies that reduce or remove the risk of allogeneic transfusion include preoperative autologous donation, acute normovolemic hemodilution, perioperative cell salvage techniques, deliberate hypotension, and pharmacologic interventions. This paper will review the current status of these therapies in the orthopedic surgical patient.
The recognition and appropriate emergency management of orthopedic emergencies is essential to minimize damage and optimize outcome. Priorities, principles and good judgment can make a difference in the overall outcome for the injured patient. These orthopedic emergencies require a team approach to assessment and care. Therefore, collaboration with other EMS providers, nurses, physicians, surgeons and other health-care personnel is essential to the proper care of the patient.
Patients who have had a cerebrovascular accident with resultant hemiplegia often present to the orthopedic surgeon with characteristic complaints and deformities. The most common of these include muscle spasticity and contracture, shoulder pain, hip fracture, and heterotopic ossification. Although some of these disorders are clinically evident, others may be easily overlooked. The purpose of this article is to summarize the most common orthopedic aspects of hemiplegic patients who have had a cerebrovascular accident.
Traditional anticoagulant drugs including vitamin K antagonists and heparins have several limitations. Despite their use, the burden of venous thromboembolism remains high, particularly in patients undergoing major orthopedic surgery. A new strategy for the design of new antithrombotic drugs is based on selective inhibition of a specific coagulation factor. Fondaparinux is a synthetic selective inhibitor of factor Xa, which is critically positioned at the start of the common pathway of the coagulation system. Its pharmacokinetic profile allows for once-daily administration without the need for laboratory monitoring or dose adjustment. Fondaparinux has demonstrated its efficacy compared to a widely used low-molecular-weight heparin in a number of thromboprophylaxis trials after major orthopedic surgery and is approved for use in this setting.
We present an emergent surgical case of massive pulmonary embolism (MPE) that happened during orthopedic surgery. A 38-year-old man, who had bone fractures with his lumbar vertebra and ankle, underwent the internal fixation of the tibial bone with tourniquet under general anesthesia in our hospital. During this surgery, the pulse oxymeter showed a drop of arterial oxygen saturation suddenly. Immediately we installed a transesophageal echo (TEE) probe in the patient, and detected enlargement of the right ventricle and right atrial thrombus. Half an hour later, the thrombus disappeared from the right atrium and the patient showed hemodynamic shock. We performed emergent embolectomy immediately under moderate hypothermic complete cardiopulmonary bypass. The postoperative course was uneventful, and one month later, his orthopedic surgery underwent completely. We conclude that TEE was a useful devise for the diagnosis of intraoperative MPE.
The objective of this study was to examine the complications associated with the orthopedic management of bladder exstrophy. The records of all patients seen for bladder exstrophy repair at the authors' institution between 1988 and 2002 were examined. Orthopedic complications were found to have occurred in 26 of 624 patients, yielding a complication rate of 4%. The observed complications were divided into five categories: bony complications at the osteotomy site, neurologic complications at the osteotomy site, complications of traction, deep infection, and late infections of the plate. Five of the 26 (19.2%) complications were bony and involved non-union, delayed union, joint pain, or leg length inequality stemming from the osteotomy. Thirteen of the 26 (50%) were neurologic complications. Four of the 26 (15.4%) resulted from traction. All were due to tight dressing around the legs following surgery. Two of the 26 (7.7%) were early deep infection and of the 26 (7.7%) were late infections. This study highlights many of the complications associated with the management of exstrophy and provides suggestions on how to minimize them.
A prospective review of all orthopedic casualties received from the southwest Asia theater of operations during Operations Desert Shield and Desert Storm was carried out at Walter Reed Army Medical Center. An injury analysis of the 181 orthopedic patients revealed 143 total fractures in 69 patients, with the remaining patients sustaining soft tissue injuries from trauma, overuse, or pre-existing conditions. Seventy percent of the fractures were open, of which 23% were treated with external fixators and 41% eventually underwent an operative stabilization procedure. An analysis of the distribution of injuries is given as well as the incidence of amputations, nerve injuries, and arterial injuries. Early multidisciplinary involvement in the care of these casualties proved to be greatly beneficial.
Medical decisions have to be founded on the current scientific state of the art. To evaluate the efficacy of any therapeutical measure, controlled clinical trials are necessary. Firstly, we describe important principles for the design and conduct of controlled clinical trials. Secondly, we list examples from the topical literature and discuss these regarding adherence to the described principles. The accepted quality criteria for clinical trials have insufficiently been transferred to the area of clinical orthopedic and traumatologic research. As a consequence, the evidence for many therapeutical measures is low. We point out frequently occurring flaws in the design and conduct of controlled clinical trials. A brief introduction to the interpretation of clinical trials and meta analyses is given. In orthopedics and traumatology, well designed controlled clinical trials have to be enforced. This is a prerequisite for evaluating therapeutical measures on a scientific basis.