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PubMed2003

Orthopedic pitfalls in the ED: osteomyelitis.

Osteomyelitis can present to the emergency department as an acute, subacute, or chronic orthopedic concern. The presentation can range from subtle, as with acute hematogenous osteomyelitis in the pediatric patient population, to obvious, as with the diabetic patient who presents with a foot ulcer overlying exposed bone. Accurate early diagnosis and prompt treatment, whether with antibiotics, debridement, or both, are important in helping determine the ultimate outcome in this potential orthopedic pitfall. We review here the clinical presentation, diagnostic techniques, and management options for osteomyelitis that are applicable to the emergency practitioner.

Aged↗
PubMedDate not supplied

Epidural anesthesia prevents hypercoagulation in patients undergoing major orthopedic surgery.

BACKGROUND AND OBJECTIVES: Epidural anesthesia (EA) is known to reduce postoperative thromboembolic complications, but mechanisms are incompletely understood. In this study, we tested the hypothesis that local anesthetics (LA) prevent postoperative hypercoagulability without affecting physiologic aggregation and coagulation processes. METHODS: Clot signature analysis (CSA) was used to assess platelet and clotting function. Venous blood samples were collected pre- and postoperatively from 41 patients undergoing major orthopedic surgery. The effect of surgery on 3 CSA parameters (platelet-mediated hemostasis time [PHT], clotting time [CT], and collagen-induced thrombus formation [CITF]) was determined in patients receiving EA (n = 20) and those receiving general anesthesia (GA) (n = 21). RESULTS: In the GA group, orthopedic surgery induced a hypercoagulable state: PHT was reduced by 39% +/- 8.6% (P <.001), CT by 21% +/- 3.3% (P <.001), CITF by 10.3% +/- 5.9% (P =.06) compared with respective baseline values. In the EA group, by contrast, no parameter was altered significantly, but PHT showed a tendency towards prolongation by 33.2% +/- 15.4% (P =.25). CT changed by 0% +/- 4.4% (P =.89), CITF by 3.8% +/- 7% (P =.78). CONCLUSIONS: Use of EA prevents immediate postoperative hypercoagulability without affecting physiologic aggregation and coagulation processes. Also, CSA appears useful in predicting hypercoagulability and detecting platelet dysfunction. Reg Anesth Pain Med 2001;26:215-222.

Adult↗
PubMed2000

Staging of bone neoplasms: an orthopedic oncologist's perspective.

The process of staging bone tumors is complex. The goal of staging is to define the type of tumor and its extent. Like staging for other neoplasms, it stratifies patients into groups based on prognosis and established treatment protocols. Staging is a multidisciplinary effort involving orthopedic oncologists, musculoskeletal radiologists, and orthopedic pathologists. The diagnosis is often suggested on clinical examination and review of the radiographs. The biopsy usually confirms the clinical and radiographic impression. However, biopsy is difficult and leads to errors in diagnosis in nearly 20% of cases. These errors may make limb salvage impossible and adversely affect survival. For this reason, staging and especially the biopsy should be done in the institution where definitive treatment is planned.

Adult↗
PubMed1990

[Value and status of neurologic, serologic, internal medicine and orthopedic studies in routine diagnosis of sudden deafness].

One hundred and eighteen patients with acute unilateral sensorineural hearing loss were examined. Diagnosis included a neurological, orthopedic, and internal medical examination. Serological tests were performed including influenza-, parainfluenza-, adenovirus-, RS-virus, enterovirus-, morbilli-, varicella- and cytomegalie-virus-KBR, also the serological tests for toxoplasmosis, rheuma, lues, mycosis, and Borrelia. The examinations allowed conclusions to be drawn about a possible etiology in five of the patients only: in one patient it was possible to detect an acute infection with morbilli virus; in two other patients, an acute lues infection was detected. In two other patients, neurological examinations showed symptoms of a brainstem disease. The authors' experience shows that the following examinations are useful in the diagnosis of acute unilateral sensorineural hearing loss: the recording of acoustically evoked brainstem potentials, an otoneurological examination, a neurological examination to detect a possible centrally located reason for the hearing loss, serological examinations for lues, toxoplasmosis, Borrelia, and the virus KBR if there is any suspicion of a previous virus infection. An orthopedic examination should be performed, if functional aspects, especially of the craniocervical segment are under consideration.

Adult↗
PubMedDate not supplied

[Ultrasonic diagnosis in orthopedics].

Ultrasonics in medicine and especially ultrasonics in orthopedics are an essential enrichment of our ways of making a diagnosis. The development of modern diagnosis instruments in addition to the systematic research of the skeletal system and soft tissues have made it possible that this method can now also be employed in the special field of orthopedics. That doesn't mean that other imaging methods should be given up but rather that this new way of imaging should be seen as a completion and a screening method for the other procedures. Because of the easiness of applying ultrasonics there is also the danger of overestimating the extent to which this method can be used and the danger of misinterpreting findings because of a lack of knowledge. Both risks should be kept in mind when using ultrasonics so that this harmless method doesn't became dangerous to the patients after all.

Arthritis, Rheumatoid↗
PubMedDate not supplied

[Schwartz-Jampel syndrome. Orthopedic and neurological problems of chondrodystrophic myotonia].

This report deals with two brothers suffering from chondrodystrophic myotomy (Schwartz-Jampel syndrome), and presents, through the study of these cases, the orthopedic and neurological problems presented by this condition. In the case of our patients there is no confirmation of the stunted growth mentioned in other reports, nor are there any changes in the vertebral column. In contrast to cases reported to date, pathologically high sero-enzyme amounts were found in both children. The congenital changes in the hip joints worsen during the pre-puberty phase, so that in one case bilateral adduction contraction and in the other complete bilateral dislocation of the hip joints resulted. Early orthopedic treatment to prevent later irreparable consequences is recommended.

Acid Phosphatase↗
PubMed1992

Report on a case of Hutchinson-Gilford progeria, with special reference to orthopedic problems.

Hutchinson-Gilford progeria is a very rare syndrome of premature aging and often features many orthopedic abnormalities. This is a case report on a young boy suffering from progeria. His orthopedic history included bilateral talus deformities of the feet, bilateral dislocated hips, pes planus, a fractured femur (which healed without complications), aseptic necrosis in the left nuclear head of the femur, bilateral fixed hip flexion deformities, bone dysplasia, osteoporosis and osteolysis.

Bone Diseases↗
PubMed1993

Orthopedic jaw movement observations. Part II: The rotational capacity of the mandible.

Using computerized axiography, particularly the electronic mandibular position indicator (EMPI), the mandibular opening movement was measured in 86 asymptomatic volunteers and temporomandibular joint (TMJ) patients. Terminal hinge-axis movement and hinge-axis rotation at maximum-guided mouth opening were recorded. The angle of hinge-axis rotation was used as a parameter for both movements, in accordance with the neutral-zero method. This is a well-established technique in orthopedics and is the standard tool for quantitative functional analysis of joints. An average group was defined, 50% being volunteers. The interquartile range for terminal hinge-axis movement in this study was 5.42 degrees-7.41 degrees in the volunteers and 4.73 degrees-7.25 degrees in the patients. The interquartile range for hinge-axis rotation at maximum opening was from 29.09 degrees-34.87 degrees in the volunteers and from 26.7 degrees-35 degrees in the patients. Computerized axiography is a refined tool for analyzing rotational and translational capacities of the mandible. It is a valid and practical method for orthopedic-diagnostic evaluation of mandibular movements and gives objective criteria for diagnosis in accident victims.

Adolescent↗
PubMed1994

Orthopedic jaw movement observations. Part III: The quantitation of mediotrusion.

The objective of this series is to observe and analyze movements of the temporomandibular joint (TMJ). With the information from these studies, orthopedic standards for jaw movements will be established in further investigations according to the neutral-zero method used in general orthopedics. Any restricted range of motion can thus be defined as a deviation from these standards. Direct interpretation and objective evaluation of joint functions has major practical implications. With the aid of computerized axiography, mediotrusive movements of 48 asymptomatic volunteers and 66 jaw patients were evaluated. The movements performed were either free or guided. The mean curve lengths, as well as the Bennett angles at 3 mm and at the end point were recorded. An average group was defined, containing the values of 50% of all volunteers. The interquartile range was calculated for lengths of mediotrusive movements as well as for Bennett angles. The average range of free mediotrusive movement for female volunteers was 11.06-11.98 mm (mean 11.55 mm) on the right side and 10.47-11.75 mm (mean 11.24 mm) on the left side. Male volunteers showed an average range of 10.23-11.54 mm (mean 11.1 mm) on the right side and 10.24-11.73 mm (mean 11.12 mm) on the left side. The values for female patients amounted to 9.95-1.66 mm (mean 10.8 mm) on the right side and 9.75-11.28 mm (mean 10.55 mm) on the left side. The average range for male patients was 9.06-9.71 mm (mean 9.54 mm) on the right side and 9.17-10.23 mm (mean 9.73 mm) on the left side. The average range for Bennett angles at maximum excursion in free mediotrusive movement was between 0.41 and 5.89 degrees (mean 4.43 degrees) in the volunteers on the right side and between 2.45 and 10.07 degrees (mean 6.87 degrees), respectively, on the left side. The values for patients amounted to 0.19-12.65 degrees (mean 6.93 degrees), on the right side and 1.71-14.15 degrees (mean 6.73 degrees) on the left side.

Adolescent↗
PubMed2005

Diagnostic ultrasound of the shoulder--a method for experts only? Results from an orthopedic surgeon with relative inexpensive compared to operative findings.

BACKGROUND: Diagnostic ultrasound examination of the shoulder is generally considered to require long experience. We examined the results of an orthopedic surgeon with little experience of ultrasound. PATIENTS AND METHODS: A relatively inexperienced examiner performed preoperative ultrasound scanning of 79 patients with symptoms from the rotator cuff and/or the long head of the biceps muscle. Tears of the rotator cuff and rupture or dislocation of the long head of the biceps muscle were the positive findings of interest. Results were compared to operative findings. RESULTS: In 66 of 79 shoulders, ultrasonographic rotator cuff findings were confirmed at surgery (accuracy 84%). 20 of 26 full-thickness tears were diagnosed correctly. 6 of 7 partial-thickness tears were overlooked. Ultrasound was false positive in 1 case. For the long head of the biceps muscle, all 8 cases of dislocation or rupture of the tendon were diagnosed but differentiation between the two conditions was not possible in 2 cases. INTERPRETATION: Our results may encourage orthopedic surgeons to start using ultrasound as a diagnostic technique for full-thickness tears of the rotator cuff and for pathology in the long head of the biceps muscle.

Clinical Competence↗
PubMed2001

Infection of orthopedic prostheses after Staphylococcus aureus bacteremia.

We prospectively evaluated 53 patients with prosthetic joints and 27 patients with other orthopedic prosthetic devices who developed Staphylococcus aureus bacteremia (SAB). After exclusion of patients with primary postoperative infections, the risk of a prosthesis becoming infected by means of hematogenous seeding after SAB was 34% (15 of 44 patients) for prosthetic joints and 7% (1 of 15 patients) for other orthopedic prostheses.

Adult↗
PubMed2001

New developments in diagnosis and treatment of infection in orthopedic implants.

Orthopedic implants have revolutionized treatment of bone fractures and noninfectious joint arthritis. Today, the risk for orthopedic device-related infection (ODRI) is <1%-2%. However, the absolute number of patients with infection continuously increases as the number of patients requiring such implants grows. Treatment of ODRIs most frequently includes long-term antimicrobial treatment and removal of the implant. Recent evidence from observational trials and 1 randomized clinical trial indicate that a subset of patients can be successfully treated with retention of the implant. Patients eligible for such a treatment must meet the following criteria: acute infection defined as signs and symptoms lasting <14-28 days, an unambiguous diagnosis based on histopathology and microbiology, a stable implant, and susceptibility of the microorganism to an effective orally available antimicrobial agent.

Humans↗
PubMed2002

Cost of venous thromboembolism following major orthopedic surgery in hospitalized patients.

The economic costs of clinical venous thromboembolism (VTE) in hospitalized patients after major orthopedic surgery were assessed. The discharge summaries and itemized bills from 220 U.S. acute care hospitals were examined. All patients who underwent total hip or knee replacement surgery or hip-fracture repair at these hospitals between January 1998 and June 1999 were identified and included in the study sample. Length of hospital stay, use of intensive care services, and costs of inpatient care were compared between patients with and without secondary diagnoses of deep vein thrombosis (DVT) without pulmonary embolism (PE) (DVT only) or PE with or without DVT. Mean length of hospital stay was more than twice as long for patients with VTE (11.5 and 12.4 days for DVT only and PE, respectively, versus 5.4 days for no VTE; p < 0.0001 for both comparisons). Mean time in the intensive care unit was roughly 10-fold greater (1.7 days for DVT only and 2.7 days for PE versus 0.2 day for no VTE; p < 0.0001). Mean total costs of inpatient care were almost twofold higher for patients with VTE ($17,114 for DVT only and $18,521 for PE versus $9,345 for no VTE; p < 0.0001 for both comparisons). Findings were unchanged in multivariate analyses controlling for differences in baseline characteristics between patients with and without VTE. Patients who develop in-hospital clinical VTE following major orthopedic surgery have significantly longer stays in the 'hospital and approximately twofold higher costs of inpatient care.

Aged↗
PubMed1979

Computer-assisted diagnosis of orthopedic gait disorders.

A computer program was developed to help diagnose orthopedic gait disorders. Designing and implementing the program, as well as the program's method of operation are described. The main features of the program include: a knowledge base of facts about orthopedic gait, organized into premise-conclusion pairs; a goal-directed reasoning chain that causally relates the facts; and a symbolic structure that allows limited English discourse between the user and the computer. Results of the project indicate that the complex area of gait analysis does lend itself to diagnosis by computer and that this prototype has potential as an aid to physical therapists in the classroom and in the clinic.

Audiovisual Aids↗
PubMed1987

Comparison of seven- and five-day physical therapy coverage in patients with acute orthopedic disorders.

This study evaluated the efficacy of seven- versus five-day physical therapy coverage in an acute care hospital setting by monitoring percentage of consecutive treatments, mean number of treatments per patient, and lengths of hospital stay (LOS) for 482 patients with acute orthopedic disorders. The Experimental Group (n = 276) received seven-day coverage; the Comparison Group (n = 206) received five-day coverage for four months. Results were analyzed for the group as a whole and by diagnostic categories. Experimental Group subjects received a higher percentage of consecutive treatments than the Comparison Group subjects (72% vs 42%). No difference was found between the groups for mean number of physical therapy treatments received per patient. The LOS was neither significantly different between the two groups as a whole nor for 9 of the 11 diagnostic categories. The results imply that providing consecutive physical therapy treatments through seven-day coverage without increasing the number of physical therapy treatments will not reduce the LOS for patients with acute orthopedic disorders.

Acute Disease↗
PubMed1998

The relationship between duration of physical therapy services in the acute care setting and change in functional status in patients with lower-extremity orthopedic problems.

BACKGROUND AND PURPOSE: This study examined the relationship between the duration of physical therapy and functional status at discharge. SUBJECTS: The subjects were 173 inpatients, with a mean age of 67.9 years (SD = 20.5, range = 18-101), referred to physical therapy with lower-extremity orthopedic problems. METHODS: For this retrospective cohort study, medical and physical therapy quality assurance records were used. Functional status, at initiation of and discharge from physical therapy, was measured using the Acute Care Index of Function (ACIF). The ACIF scores, which ranged from 0 to 100, were obtained from quality assurance records. The duration of physical therapy was the number of minutes of physical therapy billed to each patient, as determined from billing records. RESULTS: Subjects received an average of 238.5 minutes of physical therapy (SD = 153.6, range = 15-1,110). Function improved an average of 15.4 points (SD = 17.0, range = -27.4 to 64.9), and the duration of physical therapy was an important predictor of functional status at discharge after controlling for age, length of hospitalization, number of diagnoses, and initial functional status. CONCLUSION AND DISCUSSION: This study provides evidence that the amount of physical therapy that patients with some types of orthopedic problems receive is directly related to the functional improvement that occurs during hospitalization in an acute care setting.

Exercise Therapy↗
PubMed2001

Management of outpatient orthopedic surgery.

The past few years have witnessed tremendous growth in the number and complexity of orthopedic surgical procedures performed on an outpatient basis. Despite these advances, postoperative pain remains a significant problem that may limit further expansion of outpatient orthopedic surgery. Regional anesthesia plays an important role in day case surgery facilitating fast-tracking, accelerating discharge, reducing unexpected hospital admissions, and providing prolonged pain relief. Continuous peripheral nerve blockade, now possible in this setting, provides excellent perioperative care, with high patient satisfaction and improved rehabilitation scores.

Journal Article↗