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This article aims to describe and illustrate the usefulness of ultrasound in detecting complications of orthopedic implants, metal fixation devices, and other surgical material, with an emphasis on soft-tissue pathology.
In a previous prospective study, we confirmed that transfusion-related immunosuppression predisposes to postoperative infections, impairs the postoperative healing of wound and thereby prolongs hospitalization. This increases the well-known risks, such as transmission of infection or transfusion reactions, and has obliged us to revise our transfusion guidelines. We used a relational database containing information about 28,861 orthopedic surgery patients was used to determine when and how to improve these guidelines for transfusions. The survey showed the circumstances surrounding a high incidence of allogenic red cell infusions: failure to follow the guidelines, the preoperative use of nonselective NSAIDs, low preoperative Hb level, failure to retrieve blood, and high cut-off values for allogenic red cell transfusion. The first step was to determine the Hb level before giving red cell infusions and ensure compliance with predefined cut-off values. Subsequent measures included: use of COX 2-selective NSAIDs alone in the perioperative period; erythropoietin and iron therapy when the Hb level fell below 13 g/dL; use of cell salvage during and after surgery; administration of aprotinin to patients expected to have a high blood loss. The type of anesthesia had no blood-sparing effect. Although these steps can not be regarded as a new approach, we show that by following a strict rules with appropriate steps and in a concerted fashion, the use of allogenic red blood cells was reduced by 80%. Moreover, the amount of blood saved had other effects--e.g., the incidence of deep wound infections was reduced by 40%. The outcome is described in an algorithm summarizing the steps in a comprehensive perioperative diagram for giving blood.
BACKGROUND: As evidence-based practitioners, surgeons need to understand study methodology to critically appraise and conduct research. OBJECTIVE: To determine current understanding of study methodology and critical appraisal among participants at an international educational meeting. METHODS: We surveyed participants attending the 76th and 77th AO Course (December 2002) in Davos, Switzerland. We obtained information regarding participant age, gender, clinical and research experience, subspecialty area and respondents' roles in the AO course. The survey questions were formatted into three areas: evidence-based orthopedics, randomization and blinding issues. RESULTS: 532 participants completed the questionnaire. They represented 78 countries, the majority of which (31%) were from German-speaking countries. A greater proportion of participants trusted randomized controlled trials (89%) and meta-analyses of randomized trials (81%) when compared with case series and case reports. 60 respondents (11%) had never heard of the term "randomization" as a study design method to limit bias, and 114 respondents (21%) had never heard of the term "blinding" as a method of reducing bias in surgical research. When those who had heard of blinding were asked to define the term "double-blind", 20 different definitions resulted. Having completed the survey, nine-tenths of the respondents endorsed the need for training of surgeons in research methodology.
Gaucher disease, the most prevalent lysosomal storage disorder, is characterized by hepatosplenomegaly, hypersplenism, and rarely, neurological involvement. The most variable symptoms relate to skeletal disease, and both onset and progression are difficult to predict on the basis of genotype. This review describes findings from a large referral clinic (> 500 patients) and from the literature in the decade since the advent of specific enzyme replacement therapy. Such therapy is effective in reducing visceral and hematological involvement, but its greatest advantage as regards the skeleton is prevention of irreversible damage. Avascular necrosis of the joints-particularly the hips but also the knees and shoulders-and pathological fractures of the long bones including the ribs, as well as episodic "crises' of bone pain in children and young adults, are common manifestations. Various imaging modalities should be performed at baseline for life-long monitoring, and then as required because of specific complaints. Surgical interventions such as joint arthroplasties are important adjuvant treatments in this population; presurgical hematological profiling plus antibiotic cover and postoperative pain control are equally critical. Opportunities for orthopedic consultations with senior surgeons are not abused by our patients. These reflect disease-related morbidity, with greater numbers of requests being made by patients requiring enzyme therapy, who by definition have more severe disease characteristics.
Whereas continuous exposure to PTH results in bone resorption, administration at intermittent doses results in bone formation by increasing osteoblast number and activity. The anabolic action of PTH has also been demonstrated in clinical trials, in which PTH increased the bone mass and reduced fracture rate in patients with osteoporosis. In animal models of fracture healing and fixation of orthopedic implants, PTH increases the bone density in a dose-dependent manner, leading to faster repair and better fixation. The effect appears to be stronger on the new forming bone than on pre-existing bone. Based on these preclinical studies, we suggest that intermittent PTH treatment may also benefit fracture healing and implant fixation in patients.
The paper gives a bibliographical review of the finite element modeling and simulations in orthopedics from the theoretical as well as practical points of view. The bibliography lists references to papers, conference proceedings and theses/dissertations that were published between 1998 and 2005. At the end of this paper 1264 references are given dealing with subjects as: bones and their parts, special tissues; spine mechanics; movable joints and computational modeling.
An epidemiological survey of the use of antimicrobial prophylaxis in Italian hospitals was carried out under the auspices of the Journal of Chemotherapy. Out of 500 Italian orthopedic centers requested, 225 have participated in this study. A total of 136,321 surgical procedures were reported in the 166 centers reporting complete answers on type of surgery. They comprised hip and knee prosthesis (13.9%), spine surgery (4%), hip endoprosthesis (5.2%), osteosynthesis (26.9%), arthroscopy (24.4%), and others (25.5%). Perioperative antimicrobial prophylaxis was used in 75% of operations (ranging from 57.1% to 99.4% in arthroscopy and joint prosthesis, respectively). Short term (< 24 h) antimicrobial prophylaxis was performed in 38.4% of the 206 Centers answering this question correctly. 61.1% of Centers employed single agent prophylaxis. 70.8% of these prescriptions were betalactam antibiotics. Bacteriological analysis of the wound in 86 Centers (total number of isolates 2013) revealed the presence of Gram-positive isolates in 73.7% of cases. Methicillin resistance was expressed in 45% of 915 tested strains. Out of 4221 patients with high risk of infectious complications (joint prosthesis surgery) given antimicrobial prophylaxis in 46 Centers, the percentage of surgical wound infections was overall 2.1%, while that of non-surgical wound infections was 3.6%. A decrease in the total infection rate by about half was associated with long-term (> 24 h) as compared to short-term (< 24 h) antibiotic treatment (3.7 vs 7.6%, respectively), and with the use of antibiotic drug combinations vs single antibiotic drugs (3.9 vs 6.6%, respectively). The incidence of surgical-site infection is not decreased by extending the chemoprophylaxis for more than the first 24 h after surgery, while it is reduced from 2.5 to 1.4% by use of combination antibiotic therapy.
BACKGROUND: Congenital insensitivity to pain is a rare hereditary sensory neuropathy. PATIENTS: We present 6 patients from a family with a mutation in the nerve growth factor beta gene (NGFB). RESULTS: 3 patients were homozygous with a mutilating arthropathy starting early in life, and 3 patients were presumably heterozygous with a milder course starting in adulthood. All patients had normal mental abilities. In addition to absence of deep pain, the patients had impaired temperature sensation, but no autonomic deficiency. Sural nerve biopsies showed a moderate loss of A-delta fibres and a severe reduction in C fibers. Clinically, the disorder most often affected the lower extremities, with an insidious progressive joint swelling or a painless fracture, but the spine could also be involved with gross and unstable spondylolisthesis. Fracture healing was uneventful, but the arthropathy was progressive, eventually resulting in gross deformity and instability. When treating patients with congenital disorders such as this one, it is important to consider the slowly progressive nature of the disorder, and the orthopedic operations should therefore be planned from a long-term standpoint. Arthrodesis, limb lengthening and spinal decompression or fusion are the only elective procedures that seem reasonable. Fitting of orthosis for joint protection is also demanding. To delay the development of neuropathic arthropathy, patient education is essential but difficult in the very young. INTERPRETATION: The different expression between homo- and heterozygous subjects and the central role of nerve growth factor make this disease an interesting model system for studies of disease mechanisms and the molecular background to pain.
Historians have found it difficult to give a general account of the early medical use of X-rays in medicine. While the rays were hailed by some as a miracle technology, their early medical application was patchy, often remaining subsidiary to traditional methods of diagnosis and treatment, and was of disputed value. In this essay, I argue that the selective appropriation of the new technology needs to be understood within the wider medical practice of the period. The argument is developed around the case of orthopedic surgery in Germany, probably the first example in which doctors quickly made X-rays indispensable as a medical tool. I show that value of X-rays in this case was contingent upon an ongoing dispute, the theory and practice of surgical intervention, and the sociology of new surgical knowledge.
OBJECTIVE: To determine the relative importance of different risk factors for the development of surgical-site infections (SSIs) in orthopedic surgery with prosthetic implants. DESIGN: In a cohort of 272 patients, the following possible risk factors were studied: age, gender, method of hair removal, duration of operation, surgeon, underlying illness, and nasal carriage of Staphylococcus aureus. Infections were recorded following the Centers for Disease Control criteria. The relation between risk factors and SSI was tested in univariate and multiple logistic regression analysis. SETTING: Community hospital in Breda, The Netherlands. RESULTS: 18 (6.6%) of 272 patients experienced SSI: 11 superficial and 7 deep SSI. These infections led in three cases to removal of the prosthesis and caused 286 extra days in hospital. The main causative pathogen was S aureus. In multiple logistic regression analysis, the following factors were independent risk factors for the development of SSI: high-level nasal carriage of S aureus (P=.04), male gender (P=.005), and surgeon 1 (P=.006). The only independent risk factor for SSI with S aureus was high-level nasal carriage of S aureus (P=.002). CONCLUSION: High-level nasal carriage of S aureus was the most important and only significant independent risk factor for developing SSI with S aureus.
A questionnaire study was carried out of all orthopedic surgical procedures in the operating rooms of a teaching hospital over an 8-week period to describe the frequency and circumstances of accidental blood contact. Blood exposure occurred in 11% of the procedures. Contamination of intact skin was the most common incident (79%); percutaneous injury occurred in 13%. The majority of the incidents were believed to be preventable.
This review describes research on selected peptide sequences that affect cell adhesion as it applies in orthopedic applications. Of particular interest are the integrin-binding RGD peptides and heparin-binding peptides. The influence of these peptides on cell adhesion is described. Cell adhesion is defined as a sequence of four steps: cell attachment, cell spreading, organization of an actin cytoskeleton, and formation of focal adhesions. RGD sequences clearly influence cell attachment and spreading, whereas heparin-binding sequences appear to be less efficient. Collectively, these sequences appear to promote all steps of cell adhesion in certain cell types. This review also addresses issues related to peptide immobilization, as well as potential complexities that may develop as a result of using these versatile cell-binding sequences. Also described are future directions in the field concerning use of existing and more sophisticated peptide substrata.
This review covers four areas: the use of prophylactic antibiotics in orthopedic surgery not involving prosthetic devices; the use of prophylactic antibiotics in prosthetic joint implantation; the use of antibiotic-containing cement in prosthetic joint surgery; and the use of prophylactic antibiotics for dental procedures in individuals with implanted prosthetic joints. The major conclusions are as follows: (1) Prophylactic antimicrobial agents lower the rate of wound infection following surgery for closed hip fractures. (2) Antimicrobial prophylaxis reduces the frequency of deep wound infection following total joint replacement; operating rooms with ultraclean air have a similar effect. (3) Antibiotic-impregnated cement is as effective as systemic antibiotics in preventing early infection following total joint replacement. (4) For routine dental work in most patients with total joint replacement, there is insufficient evidence to support antibiotic prophylaxis; for such individuals with periodontal disease or potential dental infection, antimicrobial prophylaxis seems indicated.
A review of controlled clinical trials of antibiotic prophylaxis in orthopedic surgery is presented. Two well-designed and well-conducted studies support the efficacy of prophylactic antibiotics for prevention of wound infection in surgery of hip fractures. Several studies support a role for prophylactic antibiotics in total hip replacement, but it should be noted that equally low rates of wound infection have been attained in hypersterile operating theaters without any prophylactic antibiotics. The role of antibiotic-containing cement in total hip replacement surgery needs further critical evaluation.
About 25% of all outpatients in the emergency room at the department of orthopedics in Malmö are over 70 years of age. Fourteen per cent had no one to ask for help at home if needed. Seventy-two per cent understood the information given them correctly. About half of the patients reported satisfaction with the consultation. Three specific problems related to the service provided were identified; a long waiting time, a limited approach to the patients' problem and a lack of follow up care.
The goals of the orthopedic surgeon in the preoperative, operative, and postoperative phases of surgical reconstruction of the hip are presented. The surgeon works closely with other professionals in the care of the patient and depends especially on the physical therapist in the postoperative phase.
The focus of this article is orthopedic manual therapy for the spine: 1) precautions and contraindications for manual methods of treatment; 2) definitions of general terms for therapeutic techniques of mobilization and traction; and 3) the general concepts and the evaluation, treatment, and aftertreatment procedures of James Cyriax, MD, MRCP; Freddy Kaltenborn, DO, RPT; Geoffrey Maitland, MAPA, FCSP; and John McM. Mennell, MD.
The purpose of this qualitative case study was to further investigate the work of master and novice clinicians within the practice setting. The sample consisted of three master clinicians and three novice clinicians practicing in orthopedic outpatient physical therapy settings in three different regions of the United States. Data collection by three researchers included observation of each clinician treating at least three patients, audiotaping of all treatment sessions, interviews with clinicians and patients, and a review of patient records. Analysis of the data within and across cases revealed five attribute dimensions that distinguished the master clinician from the novice clinician. One attribute dimension (ie, confidence in predicting patient outcomes) related to knowledge, and four attribute dimensions (ie, ability to control the environment, evaluation and use of patient illness and disease data, focus of verbal and nonverbal communication with patients, and importance of teaching to hands-on care) related to improvisational performance. Further investigations are needed to confirm these findings and add to the body of knowledge concerning the parameters of physical therapy that may affect the efficacy and quality of patient care.