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PubMed2002

Epidural morphine and neostigmine for postoperative analgesia after orthopedic surgery.

UNLABELLED: In this study, we examined the side effects and analgesia of the combination of epidural neostigmine and morphine in patients undergoing orthopedic surgery. Sixty patients undergoing knee surgery were divided into four groups. The intrathecal anesthetic was 15 mg of bupivacaine. The epidural test drug was diluted in saline to a final volume of 10 mL. The control group received saline as the epidural test drug. The morphine group received 0.6 mg of epidural morphine. The neostigmine group (NG) received 60 micro g of epidural neostigmine. The morphine/neostigmine group received 0.6 mg of epidural morphine combined with 60 micro g of epidural neostigmine. The groups were demographically the same and did not differ in intraoperative characteristics. The visual analog scale score at first rescue analgesic and the incidence of adverse effects were similar among groups (P > 0.05). One patient from the NG complained of intraoperative nausea, closely related to spinal hypotension. Postoperatively, two patients from the NG had vomited once. The time (min) to first rescue analgesic was longer in the morphine/neostigmine group ( approximately 11 h) compared with the other groups (P < 0.05). The analgesic consumption (number of analgesic administrations in 24 h) was larger in the control group compared with the other groups (P < 0.05). IMPLICATIONS: The combination of epidural morphine and epidural neostigmine resulted in postoperative analgesia (11 h) devoid of side effects, being an alternative analgesic technique in the population studied.

Adult↗
PubMed1999

Transdermal nitroglycerine enhances spinal sufentanil postoperative analgesia following orthopedic surgery.

BACKGROUND: Sufentanil is a potent but short-acting spinal analgesic used to manage perioperative pain. This study evaluated the influence of transdermal nitroglycerine on the analgesic action of spinal sufentanil in patients undergoing orthopedic surgery. METHODS: Fifty-six patients were randomized to one of four groups. Patients were premedicated with 0.05-0.1 mg/kg intravenous midazolam and received 15 mg bupivacaine plus 2 ml of the test drug intrathecally (saline or 10 microg sufentanil). Twenty to 30 min after the spinal puncture, a transdermal patch of either 5 mg nitroglycerin or placebo was applied. The control group received spinal saline and transdermal placebo. The sufentanil group received spinal sufentanil and transdermal placebo. The nitroglycerin group received spinal saline and transdermal nitroglycerine patch. Finally, the sufentanil-nitroglycerin group received spinal sufentanil and transdermal nitroglycerine. Pain and adverse effects were evaluated using a 10-cm visual analog scale. RESULTS: The time to first rescue analgesic medication was longer for the sufentanil-nitroglycerin group (785+/-483 min) compared with the other groups (P<0.005). The time to first rescue analgesics was also longer for the sufentanil group compared with the control group (P<0.05). The sufentanil-nitroglycerin group group required less rescue analgesics in 24 h compared with the other groups (P<0.02) and had lesser 24-h pain visual analog scale scores compared with the control group (P<0.005), although these scores were similar to the sufentanil and nitroglycerin groups (P>0.05). The incidence of perioperative adverse effects was similar among groups (P>0.05). CONCLUSIONS: Transdermal nitroglycerine alone (5 mg/day), a nitric oxide generator, did not result in postoperative analgesia itself, but it prolonged the analgesic effect of spinal sufentanil (10 microg) and provided 13 h of effective postoperative analgesia after knee surgery.

Analgesics, Opioid↗
PubMed1999

Perflubron emulsion delays blood transfusions in orthopedic surgery. European Perflubron Emulsion Study Group.

BACKGROUND: Fluorocarbon emulsions have been proposed as temporary artificial oxygen carriers. The aim of the present study is to compare the effectiveness of perflubron emulsion with the effectiveness of autologous blood or colloid infusion for reversal of physiologic transfusion triggers. METHODS: A multinational, multicenter, randomized, controlled, single-blind, parallel group study was performed in 147 orthopedic patients. Patients underwent acute normovolemic hemodilution with colloid to a target hemoglobin of 9 g/dl with an inspiratory oxygen fraction (FIO2) of 0.40. Patients were then randomized into one of four treatment groups after having reached any of the protocol-defined transfusion triggers including tachycardia (heart rate > 125% of posthemodilution rate or > 110 bpm), hypotension (mean arterial pressure < 75% of posthemodilution level or < or = 60 mmHg), elevated cardiac output (> 150% of posthemodilution level) or decreased mixed venous oxygen partial pressure (PVO2; < 38 mmHg). Treatments in the four groups were 450 ml autologous blood harvested during acute normovolemic hemodilution given at FO2 = 0.40; 450 ml colloid at FIO2 = 1.0; 0.9 g/kg perflubron emulsion with colloid (total = 450 ml) at FIO2 = 1.0; and 1.8 g/kg perflubron emulsion with colloid (total = 450 ml) at FIO2 = 1.0. The primary endpoint was duration of transfusion-trigger reversal. A secondary end-point was percentage of transfusion-trigger reversal. RESULTS: Perflubron emulsion was well tolerated with no serious adverse event attributed to drug treatment. Duration of reversal was longest in the 1.8 g/kg perflubron group (median, 80 min; 95% confidence interval, 60-100 min; P = 0.014 vs. autologous blood, P < 0.001 vs. colloid) followed by the 0.9 g/kg perflubron group (median, 59 min; 95% confidence interval, 40-90 min), the autologous blood group (median, 55 min; 95% confidence interval, 30-70 min) and the colloid group (median, 30 min; 95% confidence interval, 27-60 min). Percentage of reversal was also highest in the 1.8 g/kg perflubron group (97%; P < 0.001 vs. autologous blood; P = 0.014 vs. colloid), followed by 0.9 g/kg perflubron (82%), colloid (76%), and autologous blood (60%). CONCLUSIONS: Perflubron emulsion (1.8 g/kg) combined with 100% oxygen ventilation is more effective than autologous blood or colloid infusion in reversing physiologic transfusion triggers.

Aged↗
PubMedDate not supplied

Orthopedic management of acquired cerebrospasticity in childhood.

Of 221 children with head injuries and resultant deep coma followed for long-term problems, 156 became totally independent, functional individuals, only 61 lacking normal cognition and speech. Reconstructive surgical procedures for residual spasticity was necessary in 45 patients. Achilles lengthenings were the most common procedure performed; after Achilles lengthenings, toe flexor releases were most often required. Twenty children had anoxia from drowning or anesthesia problems; 7 of these had spastic hip deformities or dislocations, all within 6 months of the anoxic event. Progressive cerebrospastic syndromes and post-infectious cerebrospasticity most often require orthotic devices for their orthopedic management.

Achilles Tendon↗
PubMed2005

Prediction of costs-of-illness in patients with low back pain undergoing orthopedic outpatient rehabilitation.

The objectives of this study were (1) to assess societal costs-of-illness and their changes in the year prior to and after outpatient rehabilitation (OPR) in initially gainfully employed persons with low back pain and (2) to identify predictors (cost drivers) for high overall costs in the year after the intervention. The health economical analysis is part of a prospective clinical trial investigating patients participating in orthopedic OPR. In all gainfully employed patients (n=244) resource consumption and productivity losses were assessed prior to OPR and 12 months afterwards. Overall annual medical costs per person were estimated. Parameters associated with high overall costs in the 12 months after OPR were predicted by multivariate logistic regression analysis. All sociodemographic, motivational, clinical, psychological, therapeutic and vocational variables were included as possible predictors. Costs due to sick leave periods represent the major component (83%/58%) of overall costs in both periods. The comparison of costs 12 months before and after OPR reveals a significant reduction from 8050 to 3200 per person, primarily caused by decreasing sick leave costs and the reduction of costs related to inpatient treatment. The prediction analysis reveals that patients with limited functional abilities, with problems due to strenuous labour, with low expectations in terms of possible improvement after OPR, with a high pain score or with limited satisfaction with working colleagues have a significantly higher risk for costs exceeding 2200 after OPR. The identified cost drivers can be used to develop multimodal therapeutic measures, which should be employed during the OPR intervention in order to prevent future costs.

Adult↗
PubMedDate not supplied

Glove perforation in pediatric orthopedic practice.

A prospective study was conducted to assess the glove perforation rate during 100 consecutive pediatric orthopedic operations. Eight hundred fifty-four gloves were tested for perforations. The overall glove perforation rate was 8.43%. Assistant surgeons had a rate of 45.8%, surgeons 33.4%, and scrub nurses 20.8%. More perforations were noticed on the left glove; the thumb and index finger were the most common sites of perforation. The duration of surgery was significantly related to the perforation rate. Two patients had postoperative wound infections and the gloves of surgeons and assistant surgeons were found to be perforated. Every attempt needs to be made to reduce the risk of glove perforation.

Equipment Failure↗
PubMed2001

Outcomes among orthopedic patients in skilled nursing facilities: does managed care make a difference?

The use of rehabilitative care has increased greatly. This study evaluates whether managed care affects health outcomes among Medicare orthopedic patients receiving rehabilitative treatments. Managed care versus fee-for-service patients had better outcomes at four months following discharge from skilled nursing facilities. It is important to address predictive factors, such as age, length of hospital stay, debilitation and social living arrangements, which can also influence health outcomes when planning rehabilitative treatment for older patients.

Age Factors↗
PubMed1976

Case finding of unrelated disease in the orthopedic clinic.

Protocols for detecting hypertension and pelvic disease were established in the orthopedic outpatient department. A significant percentage (hypertension, 20%; pelvic disease, 10%) of the patients were found to have undiagnosed pathologic conditions. The cost to the orthopedist of such case finding was minimal in terms of time and money. Methods of securing adequate follow-up are discussed.

Adult↗
PubMed1977

Prophylactic antibiotics in elective orthopedic surgery: a prospective study of 1,591 cases.

A double-blind prospective study involving 1,591 clean orthopedic surgical procedures was done to test the effectiveness of preoperative and intraoperative antibiotics in reducing the postoperative infection rate. The antibiotic and placebo groups were analyzed carefully for factors known to predispose to infection. Several minor exceptions were noted, but generally the antibiotic and placebo groups were comparable with regard to these factors. A decrease in overall postoperative infection rate from 5.0% in the placebo group to 2.8% in the antibiotic group was found. In specific areas such as the hip and spine a much greater reduction in postoperative wound infections occurred than in the group as a whole.

Adult↗
PubMed1979

Control of orthopedic nosocomial wound infections.

The catastrophic effects of deep sepsis as a complication of total joint replacement, especially the hip and the knee, are well documented. This review identifies risk factors predisposing to surgical wound infection. Proven, investigational, and theoretic methods of reducing nosocomial wound infection rates, particularly pertaining to orthopedic procedures, are given.

Air Microbiology↗
PubMed1982

Chemoprophylaxis in cardiac and orthopedic surgery: comparison of cephalothin and cephapirin.

In a retrospective sequential study we determined the rate of infection occurring despite cephalothin or cephapirin chemoprophylaxis in orthopedic and cardiac surgery done from 1973 to 1977. The incidence of infection after prosthetic hip placement or open reduction of hip fracture was 3.4% and 1.0% in patients receiving cephalothin or cephapirin, respectively. The infection rate after prosthetic heart valve implantation was 3.5% in those receiving cephalothin and 1.6% in those receiving cephapirin. There was no significant difference in infection rate, duration of fever greater than or equal to 38.0 C, or length of postoperative hospitalization. The efficacy of selected antistaphylococcal antibiotics in preventing colonization of human fibrin clots by staphylococci was studied. Although cephapirin was effective at lower concentration, the activity of cephalothin and cephapirin was comparable. Cephalothin and cephapirin have equivalent chemoprophylactic activity by clinical and microbiological criteria, permitting cost to be used as a basis for choosing between these antibiotics.

Cardiac Surgical Procedures↗
PubMed2002

Alcohol neurolysis for persistent pain caused by superior cluneal nerves injury after iliac crest bone graft harvesting in orthopedic surgery: report of four cases and review of the literature.

STUDY DESIGN: Harvesting of autologous bone graft from the posterior iliac crest for lumbar spinal fusions is a frequently performed procedure in orthopedic surgery. The most common complication associated with this procedure is an alteration in sensation over the donor site manifested as chronic pain, hyperesthesia, dysesthesia, or diminished sensitivity resulting from superior cluneal nerve (SCN) injury. OBJECTIVE: To predict the effectiveness of alcohol neurolysis in the treatment of persistent pain caused by the entrapment of superior cluneal nerves. SUMMARY AND BACKGROUND DATA: The subjects of this study were patients with intractable pain in donor area after conventional treatments using a transverse incision, which is parallel to posterior iliac crest. The study group was composed of four patients who underwent surgery in a 1-year period and experienced chronic pain resulting from superior cluneal nerve injury. METHODS: No reports describing alcohol neurolysis of the superior cluneal nerve exist in the relevant literature. All four patients in this study were treated with alcohol neurolysis of the superior cluneal nerves. RESULTS: The study patients were observed up to 4 years, and none of them reported any problems. CONCLUSIONS: The authors suggest that conventional treatments be limited to a 2-month period, and that alcohol neurolysis be applied as soon as possible to prevent lengthy pain experiences.

Adult↗
PubMed2002

Orthopedic management of the muscular dystrophies.

Muscular dystrophy is a collective group of inherited, noninflammatory, progressive muscle wasting diseases. The initial pathologic feature is an abnormality in the genetic code for dystrophin or one of its associated glycoproteins, which leads to the various clinical syndromes. Despite minor variations between the different types, all muscular dystrophies have in common progressive muscle weakness, which is best typified by Duchenne muscular dystrophy. The weakness occurs in a proximal to distal direction and can compromise ambulatory status as well as cardiopulmonary function. Additionally, structural soft tissue contractures and spinal deformities may develop from poor posturing secondary to the progressive muscle weakness and imbalance. The rapidly developing scoliosis and its associated pelvic obliquity can even compromise sitting. Recent advances in molecular biology and gene therapy research raise the hope for a cure for muscular dystrophy in the near future. Until that time, however, the role of orthopedic surgeons in treating patients with muscular dystrophy is to preserve or prolong their functional status for as long as possible. This can be achieved by physical therapy, bracing, soft tissue releases for joint contractures, and early stabilization of the spine.

Child↗
PubMed2003

Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review.

OBJECTIVE: To review randomized controlled trials evaluating the effectiveness of therapeutic exercise and orthopedic manual therapy for the treatment of impingement syndrome. DATA SOURCE: Reports up to October 2002 were located from MEDLINE, the Cochrane Database of Systematic Reviews, the Physiotherapy Evidence Database (PEDro), the TRIP database, and the Cumulative Index to Nursing & Allied Health Literature (CINAHL) using "shoulder" and "clinical trial"/"randomized controlled trial" as search terms. STUDY SELECTION: Studies were included if (1) they were a randomized controlled trial; (2) they were related to impingement syndrome, rotator cuff tendinitis, or bursitis; (3) one of the treatments included therapeutic exercise or manual therapy. DATA EXTRACTION: Two independent observers reviewed the methodological quality of the studies using an assessment tool developed by the Cochrane Musculoskeletal Injuries Group. Differences were resolved by consensus. DATA SYNTHESIS: Seven trials met our inclusion criteria. After consensus, the mean methodological score for all studies was 13.9 +/- 2.4 (of 24). Four studies of 7, including the 3 trials with the best methodological score (67%), suggested some benefit of therapeutic exercise or manual therapy compared with other treatments such as acromioplasty, placebo, or no intervention. CONCLUSIONS: There is limited evidence to support the efficacy of therapeutic exercise and manual therapy to treat impingement syndrome. More methodologically sound studies are needed to further evaluate these interventions.

Exercise Therapy↗
PubMed2003

Fractures in young children: are physicians in the emergency department and orthopedic clinics adequately screening for possible abuse?

OBJECTIVES: 1) To determine whether physicians are sufficiently investigating the cause of fractures in children younger than 3 years and 2) to find out what influences physicians' quality of history taking and documentation necessary to rule out inflicted trauma. DESIGN: Descriptive, retrospective chart review. SETTING: Pediatric emergency department and orthopedic clinic of an urban teaching hospital. SUBJECTS: Children younger than 3 years treated between January 1, 1995, and December 31, 1998, presenting with a fracture. RESULTS: A total of 653 charts met entry criteria. Information that was significantly lacking in the recorded history included witness presence, history of previous injury, review of past medical record, other injury description, and whether the injury was consistent with the development of the child. It was not possible to rule out inflicted injury in 42% of the patients. Four groups emerged from the entire cohort: group 1, accidental trauma, which made up 63% of the entire group (n = 413); group 2, inflicted trauma, which made up 13% (n = 85); group 3, missed inflicted trauma, which made up 23% (n = 151); and group 4, missed accidental trauma, which made up 0.6% (n = 4). Younger age of the child, multiple fractures, need for hospital admission, and the examining physician being a pediatrician positively influenced physicians' propensity to accurately report inflicted trauma. CONCLUSIONS: A large percentage of the charts reviewed contained inadequate documentation to explain the cause of fractures and thereby rule out inflicted trauma. Information in 23% of the charts reviewed aroused suspicion of inflicted trauma. There is a need to ensure that adequate information is obtained and documented in hospital records to rule out inflicted injury. This will require changes in the knowledge, skills, and attitudes of physicians. The use of forms, protocols, and periodic chart review will help to ensure compliance.

Accidents↗
PubMed2005

Orthopedic impairment after medical rehabilitation: functional performance and satisfaction with community participation.

OBJECTIVE: To determine the prevalence of satisfaction with community participation and to examine associations between change in functional status and satisfaction with community participation for persons with orthopedic impairments. DESIGN: Retrospective study of 3832 patients discharged from medical rehabilitation facilities in 2001 using information from the IT Health Track database. RESULTS: Primary measures were the FIM instrument and satisfaction with community participation. The majority of patients (86.9%) were satisfied (very or somewhat) with their level of community participation. Positive-change scores in FIM total from admission to the 80- to 180-day follow-up were associated with an 8% increased odds of being in a higher satisfaction with community participation level (odds ratio, 1.08; 95% confidence interval: 1.07, 1.09) after controlling for age, gender, marital status, race/ethnicity, insurance source, length of stay and functional status. Similarly, positive-change score in motor (odds ratio, 1.09; 95% confidence interval: 1.08, 1.10) and cognition (odds ratio, 1.26; 95% confidence interval: 1.19, 1.32) FIM measures from admission to follow-up were associated with greater satisfaction with community participation. CONCLUSION: Gains in functional status were significantly associated with greater satisfaction with community participation. Satisfaction with community participation provides information useful to evaluate patient recovery after discharge from inpatient medical rehabilitation.

Adult↗
PubMed2004

A 2-year follow-up of outcomes following orthopedic surgery or selective dorsal rhizotomy in children with spastic diplegia.

The purpose of this study was to prospectively compare the effect of orthopedic surgery (OS) and selective dorsal rhizotomy (SDR) on muscle tone, range of motion, gait and energy efficiency in ambulatory children with spastic diplegia. Twenty-five children with a diagnosis of spastic diplegia, with a mean age of 73 months, were evaluated prior to surgery and 1 and 2 years postoperatively; however, only the preoperative and 2-year postoperative data are reported here. Eighteen children received SDR and seven received OS. Children were evaluated with the Ashworth scale for muscle tone, passive range of motion (PROM), gait analysis and oxygen consumption for energy cost. Significant improvements were seen in PROM, muscle tone, gait kinematics and oxygen cost regardless of surgical intervention. Although OS and SDR interventions influence motor function through different mechanisms, the gait and energy outcomes 2 years following OS or SDR are similar.

Cerebral Palsy↗
PubMed2006

A novel elastic exsanguination tourniquet as an alternative to the pneumatic cuff in pediatric orthopedic limb surgery.

We describe our experience with a novel surgical exsanguination tourniquet (S-MART; OHK Medical Devices, Haifa, Israel) in clinical pediatric orthopedics. We evaluated the surgical exsanguination tourniquet's properties and clinical use in 51 patients and compared our observations with our long-standing experience with the Esmarch bandage, pneumatic tourniquet and sterile stockinet. Using the surgical exsanguination tourniquet, we found superior exsanguination quality, quick application and the ability to place the occlusion ring closer to the surgical field. No side effects or ischemic complications were observed. After removal, the skin under the ring was intact in all cases. We conclude that the surgical exsanguination tourniquet is safe and valuable in our practice.

Adolescent↗