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PubMed1982

Learning outcomes and practice changes after a postgraduate course in office orthopedics.

Although many of studies of continuing medical education have demonstrated information transfer and some have resulted in practice changes, little is known about the relationships between physician knowledge, intentions, and actual changes in clinical behavior. This paper presents the results of a study of immediate and delayed learning outcomes, including a parallel exploration of physician intentions and practice changes for three tracer procedures, among 83 physicians attending a post-graduate course in office orthopedics. A high level of knowledge gain and retention was found, and considerable change in practice behavior occurred in self-reported use of torsional profiles, ordering of shoulder arthrograms, and discontinued use of corrective shoes. Discrepancies between physicians' cognitive knowledge, their intentions to apply that knowledge, and reported clinical behavior were consistent with a conservative approach to orthopedic management among the primary care physicians studied.

Attitude of Health Personnel↗
PubMed1978

Orthopedic outpatient surgery.

Changes in provision of health care by the province of Ontario have included forced reduction in the number of hospital beds. In this situation the needs of patients with orthopedic disabilities have been met by a dramatic increase in outpatient surgery. At the Hotel Dieu Hospital, Kingston, the total number of surgical procedures increased from 5516 in 1970 to 7260 in 1975. During this period the number of outpatient surgical procedures performed under general anesthesia rose from 820 in 1970 to 2927 in 1975, an increase of 264%. Of 1197 orthopedic procedures performed in 1975, 632 (52%) were performed on an outpatient basis. In the author's personal experience of outpatient surgery, which in 1975 included 38 meniscectomies, 10 major shoulder repairs, 28 foot reconstructions, 11 nerve releases, 14 tendon releases and 4 elbow arthroplasties, patient acceptance has been good. Adequate clinic facilities, trained nurses, appropriate anesthesia and patient education are essential if management in this locale is to be successful.

Adult↗
PubMedDate not supplied

The orthopedic surgeon and rehabilitation engineering.

Rapid advancements in technology in the past 30 years have brought about a close relationship between medicine and engineering. Part of this has been the close association of orthopedics and the prosthetics and orthotics technologies. In recent years, advances in other aspects of rehabilitation engineering have taken place; these have been partly based on the technology established by research in prosthetics and orthotics. The rapid progress in rehabilitation engineering now demands the attention of orthopedists. The role of the rehabilitation engineer is defined, and some examples are given of the kinds of problems confronted by the rehabilitation engineering clinic team. Especially as further progress takes place, the orthopedic surgeon and the prosthetist-orthotist need to obtain more knowledge of the technical aids needed to restore independence to the disabled.

Biomedical Engineering↗
PubMed1981

Cutaneous complications of orthopedic implants. A two-year prospective study.

In a two-year prospective study of cutaneous problems in orthopedic implant recipients, cutaneous eruptions of unknown cause that bore good temporal relationships with implant surgery occurred in 19 patients. Two clinical patterns were observed. A transient "exanthematic" dermatitis was seen in six patients; in two of them, it recurred after each surgical implant procedure. A persistent reaction was seen in 13 patients. Metal sensitivity was found in two patients and considered to be relevant. Allergic cutaneous complications of orthopedic implants are rare. However, in an implant recipient in whom a cutaneous problem develops, the likelihood of the cutaneous problem being allergic in nature is slightly greater if the implant is of the static type, if there is a history of metal sensitivity, if the cutaneous eruption shows a predilection for the anatomic zone of the implant, and if the eruption is eczematous and has developed late and persisted.

Adult↗
PubMed1995

Orthopedic injuries experienced by U.S. prisoners of war during Operation Desert Storm: a descriptive analysis.

U.S. prisoners of war from Operation Desert Storm suffered significant orthopedic injuries. The repatriated prisoners of war (RPOWs) have been medically evaluated over a 3-year period with orthopedic follow-up. A significant proportion of the musculoskeletal injuries were located around the neck and spine, shoulder, and upper extremity. Aircraft ejection was the cause of the majority of these injuries. Lower extremity injuries after ejection, aside from the knee, were not reported. Flail injuries of the lower extremities were absent as well. These results were examined with reference to Vietnam RPOW data.

Adult↗
PubMed1995

The Peter Principle in orthopedics.

Original orthopedic devices that were developed, tested, and found useful, were subsequently modified and seemingly "improved" to a point of diminished usefulness--a manifestation of the Peter Principle applied to orthopedics. The authors describe seven examples: (1) the talar-tilt inversion apparatus; (2) the patellar-tendon-bearing, below-knee amputation prosthesis; (3) the patellar-tendon-bearing orthosis; (4) the Veterans Administration Prosthetic Center's lumbosacral orthosis; (5) the partial-foot prosthesis; (6) the ankle-foot orthosis; and (7) the occipito-zygomatic cervical orthosis.

Artificial Limbs↗
PubMed1995

[Perioperative management of dialysed patients for orthopedic surgery].

Recently, renal osteodystrophy is a remarkable problem in patients on long-term hemodialysis (HD). In this retrospective study, we evaluated the perioperative management of 21 patients receiving orthopedic surgery between January 1990 and December 1992. These patients had been maintained on HD for an average of 8.6 years (range, 18 months-20 years). The primary causes of orthopedic surgery were amyloidosis, diabetic gangrene, rheumatoid arthritis and fractures. Laminectomy, replacement of arthropathy, osteosynthesis and amputation of the lower extremity were undertaken. General anesthesia was performed on six patients. Vecuronium was given to all of these patients. Isoflurane was used in 5 patients and sevoflurane in 1 patient. Regional anesthesia was used in 15 patients. During anesthesia, the average infusion rate of intravenous fluids was 2.7 ml.kg-1.h-1, and the intraoperative complications included hypertension in 16, hypotension in 12, arrhythmia in 4 and prolonged sedation in 2 patients. Postoperative complications included hyperkalemia in 2, pneumonia in 2, psychological disorder in 3, clotting fistula in 1 and delayed wound healing in 7 patients. One early death in a diabetic patient following amputation occurred on the 13th postoperative day. Preoperative HD was performed within 24 hours and postoperative HD within 72 hours of the operation. Nafamostat mesilate was used as an anticoagulant. Excessive removal of potassium must be avoided during preoperative HD to prevent arrhythmia. The well-managed elective patients gave a good result. However, extreme care in nutrition and infection control should be taken, especially in diabetic patients.

Anesthesia↗
PubMed1993

Blood lost and transfused in patients undergoing elective orthopedic operation.

Autologous blood predeposit is a widely used transfusion practice that has become a standard of care for elective orthopedic operation. Despite the support for this practice, there are limitations in the use and efficacy of autologous blood programs. This study is a prospective analysis of 385 orthopedic patients in whom a type and crossmatch were requested in which 249 patients predonated autologous blood and 136 patients did not. Preoperative anemia, blood lost and the "transfusion trigger" were evaluated for each of these patients. We conclude that the prevalence of anemia (25 percent) and rate of homologous blood exposure (25 percent) in autologous blood donors indicate a need for innovative blood conservation strategies to minimize homologous blood transfusion in this patient subgroup; the high prevalence of anemia (39 percent) and the homologous blood exposure (49 percent) in patients who did not donate autologous blood demonstrate a need for early recognition and treatment to procure autologous blood and reduce homologous blood exposure in these patients. The procurement of three to eight autologous blood units, along with the regeneration of a erythrocyte volume of 8 to 12 milliliters per kilogram, would avoid homologous blood transfusion in 95 percent of the patients in this setting.

Blood Loss, Surgical↗
PubMed1993

[Treatment of hip fractures in a department of general surgery and a department of orthopedic surgery. A comparison].

All patients treated for fractures of the hip in 1989 in a department of general surgery and a department of orthopedics were included in this study. Data regarding demographics, length of hospitalization, rehabilitation, postoperative complications, types of fractures and modes of operation were retrospectively registered and compared. Mean length of hospitalization was significantly longer and the incidence of postoperative complications was significantly higher in the department of general surgery when compared to the specialized department of orthopedics especially with regard to wound infections and the formation of bedsores. We tentatively propose reasons for these differences.

Adult↗
PubMed1993

Industry's contribution to quality orthopedic care.

The orthopedic industry complies with strict manufacturing standards when producing orthopedic implants. Adherence to these standards assures the surgeon, nurse, and patient of the highest quality implants both in their material composition and in their manufacturing processes so that the maximum benefit can be achieved from the surgical procedure.

Humans↗
PubMed1993

Infection prevention and management in orthopedic surgery.

With all the technological advances made in orthopedic surgery over the years, infection remains the most prevalent postoperative complication. Nationwide figures from the American College of Surgeons demonstrate an infection rate in orthopedic surgery between 5% and 7% for clean cases. The minimum infection rate is 1%. The important principle to remember is that there is no substitute for strict adherence to standard, well-known aseptic surgical techniques for all surgical procedures.

Humans↗
PubMed1993

A retrospective review of orthopedic patients returning from Operations Desert Shield and Desert Storm to an Army Medical Center.

A retrospective review of all casualties received related to Operations Desert Shield and Desert Storm was conducted at Madigan Army Medical Center. Of the 180 patients determined to have returned from the Persian Gulf theater of operations, 93 (52%) had at least one orthopedic diagnosis and 84 (45%) were transported with a primary orthopedic diagnosis. The evacuation diagnosis was not substantiated by medical center evaluation in 37 (40%), and 42 (45%) were returned to duty without further treatment. Thirty-five patients (38%) were evacuated for a condition for which they had previously been profiled at least once. Peacetime duty limitations must be accurate and appropriate with respect to potential wartime demands.

Hospitals, Military↗
PubMed1995

Changes in coagulatory profile after orthopedic surgery.

Platelet count, prothrombin time (PT), partial thromboplastin time (PTT) and fibrinogen concentrations were prospectively evaluated in 65 patients undergoing orthopedic surgery at the National Cheng-Kung University Hospital between June 1990 and February 1991. All patients were hospitalized for at least 7 days after surgery. Coagulation data were collected preoperatively and on the first, third and seventh postoperative days (POD 1, 3, 7). The average estimated blood loss was 374 mL (range, 25-2.350 mL). Stored whole blood transfusion of 2 to 5 units (1 unit = 250 mL) was required by 12 patients. A further 12 patients received a transfusion of two to six units of packed red cells. Platelet count decreased to the lowest level on POD 1, recovered to normal on POD 3 and was even greater by POD 7. PT was prolonged on POD 1, recovered by POD 3 and remained stable on POD 7. PTT was prolonged on POD 1, became more prolonged on POD 3 and returned to normal by POD 7. Fibrinogen concentrations were not significantly altered on POD 1, but increased above the preoperative level on POD 3 and returned gradually to normal by POD 7. Variables such as age, sex, type of operation and duration of tourniquet did not affect these patterns. There was a positive correlation between duration of surgery, net blood loss and decrease in platelet count. This study examined some of the physiologic coagulatory variations after orthopedic surgery. Recognition of these patterns might lead to better clinical judgment when perioperative coagulatory disorders are suspected.

Adolescent↗
PubMed1996

Epoetin alfa as an adjunct to autologous blood donation in patients with a low hematocrit scheduled for elective orthopedic surgery.

Predonation of autologous blood (AB) represents an attractive alternative to allogeneic blood transfusion in patients scheduled for elective orthopedic surgery. However, anemic patients may not be able to donate sufficient AB prior to surgery, thus increasing the risk of exposure to allogeneic blood. This group of patients may benefit from the administration of epoetin alfa to facilitate AB donation. A recent multicenter, double-blind, placebo-controlled study in 204 patients with a low hematocrit (Hct; < or = 39%) scheduled for orthopedic surgery demonstrated that the intravenous administration of epoetin alfa (600 IU/kg twice weekly for 3 weeks) significantly increased the number of AB units predeposited and the percentage of patients able to donate > or = 4 AB units. Furthermore, epoetin alfa attenuated the decrease in Hct associated with AB donation and significantly (P = .027) reduced allogeneic blood exposure in these patients.

Anemia↗
PubMed1996

Epoetin alfa plus autologous blood donation in patients with a low hematocrit scheduled to undergo orthopedic surgery.

A low predonation hematocrit (Hct) can preclude the collection of sufficient autologous blood (AB) to meet the transfusion requirements of patients scheduled for orthopedic surgery. Subcutaneous (s.c.) administration of epoetin alfa, in conjunction with intravenous (i.v.) iron supplementation, has proved effective for the facilitation of AB donation by such patients. Compared with untreated controls and patients treated with i.v. iron alone, epoetin alfa 50 to 150 IU/kg SC plus i.v. iron twice weekly for 3 weeks prior to surgery significantly increased total red blood cell (RBC) production (P < .01) and the volume of RBCs donated (P < .05). Epoetin alfa was particularly effective in females and patients with a predicted blood volume (PBV) less than 5 L. Treatment with epoetin alfa led to an increase (albeit nonsignificant) in the number of AB units predonated compared with i.v. iron alone. However, in patients with a PBV less than 5 L, a substantially greater percentage of epoetin alfa-treated patients donated > or = 4 AB units (80% v 30%). Allogeneic blood requirements were reduced, albeit not significantly (P = .051), in patients treated with epoetin alfa. However, in comparison with untreated controls, there was a significant reduction in the mean volume of allogeneic blood transfused per transfused patient in the epoetin alfa groups. The optimum s.c. dose of epoetin alfa in patients with a low predonation Hct scheduled for orthopedic surgery appears to be between 100 and 150 IU/kg twice weekly for 3 weeks.

Anemia↗
PubMed1996

Perisurgical use of epoetin alfa in orthopedic surgery patients.

In order to avoid exposure to allogeneic blood, perisurgical administration of epoetin alfa has been proposed as an alternative to autologous blood (AB) predonation in patients who are unable or unwilling to donate AB prior to elective surgery. The efficacy of perisurgical epoetin alfa to reduce allogeneic blood exposure was investigated in a randomized, double-blind, placebo-controlled study in 200 patients unable to participate in an AB predonation program who were scheduled for orthopedic surgery with expected blood loss > or = 2 units. Epoetin alfa (100 IU/kg or 300 IU/kg) was administered daily by subcutaneous (s.c.) injection, commencing 10 days preoperatively and continuing until day 4 postoperatively (15 doses in total). All patients received oral iron supplementation. Patients treated with epoetin alfa required significantly fewer (P < .001) allogeneic transfusion compared with placebo, and this effect of epoetin alfa was particularly evident in the subgroup of patients with baseline hemoglobin (Hb) levels of more than 10 to < or = 13 g/dL. In terms of the reduction in allogeneic blood exposure, no significant difference was evident between epoetin alfa regimens. Epoetin alfa was well tolerated. Although 15 s.c. doses of epoetin alfa 100 IU/kg appears to be the optimum dosage regimen in patients scheduled for orthopedic surgery, a presurgical simulation study in 24 healthy volunteers suggested that two s.c. doses of epoetin alfa 600 IU/kg in 10 days prior to expected surgery may be a suitable regimen for further study. However, the optimum timing of epoetin alfa administration in relation to surgery remains to be established. A finding consistent to all studies is that adequate iron supplementation (most probably in parenteral form) is necessary to optimize the erythropoietic response to epoetin alfa in the surgical setting.

Anemia↗
PubMed1977

Who is responsible for elderly patients on orthopedic wards?

A retrospective survey of the geriatrician's role on the orthopedic ward showed that his or her main aim should be to advise the orthopedic team of the advantages of long-term planning for every elderly patient admitted. From the moment of the initial assessment, it is important to emphasize the need for a more detailed medical, social, and psychiatric history; to alter the management of incontinence; and to point out the differences in the nursing and rehabilitation requirements of elderly patients. Once this is achieved, the geriatrician should revert to the role of the clinical adviser in medical diseases affecting the elderly.

Aged↗
PubMed1995

[Prevalence of viral hepatitis in candidates for orthopedic surgery].

OBJECTIVES: To study the prevalence of positive serology results for hepatitis B and C viruses among patients scheduled for elective orthopedic surgery, to establish risk groups and to assess the economic cost involved in testing patients in such groups. PATIENTS AND METHODS: We performed a retrospective study of 1090 preoperative charts for patients awaiting elective orthopedic surgery between November 1993 and January 1995. Variables recorded were age, sex, physical status, history of alcoholism or addiction to injected drugs, associated disease (liver disease, chronic kidney failure and hemodialysis, and coagulation disorders), history of blood products transfusion, preoperative liver enzymes and blood levels of AcVHC and AgVHB as determined by enzyme immunoassay. RESULTS: Mean age was 51.8 (SD 17.5). Women predominated, accounting for 60.6% of the sample. ASA I and ASA II patients accounted for 84.9%, 72 (6.61%) had had previous transfusions, 51 (4.6%) suffered liver disease, 4 (0.36%) had coagulation disorder, 5 (0.45%) were receiving hemodialysis for chronic kidney failure, and 5 (0.45%) admitted having injected drugs. We discovered alterations in preoperative liver enzyme levels in 116 (10.6%) cases. Sixty-five (5.96%) were positive for AcVHC and 13 (1.19%) were positive for AgVHB. Factors that predicted positive results for hepatitis C and B were liver disease, previous administration of blood products, chronic kidney failure requiring hemodialysis, drug addiction and high preoperative liver enzyme levels. Serologic testing for viruses performed on patients in this risk group would have detected 76.6% of the positive cases, resulting in savings of 90% of the cost of indiscriminate testing. CONCLUSIONS: We believe that patients with histories of liver disease, blood product transfusion, chronic kidney failure with hemodialysis or drug addiction, or with high liver enzyme levels should be tested for hepatitis B and C before surgery.

Adult↗