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PubMed2004

Perioperative pain management of a complex orthopedic surgical procedure with double continuous nerve blocks in a burned child.

UNLABELLED: The use of catheters for continuous nerve blocks has been established in children, although in most series only one catheter was used. We report a case of a 3-yr-old child who underwent a toe-to-finger transfer managed with 2 regional catheters: axillary and sciatic. A pain score of 0 was noted during the entire study period. The total dose of bupivacaine was limited to an acceptable range, and the child recovered completely. This report adds to growing evidence in favor of the safety and efficacy of continuous peripheral nerve blocks in pediatric patients. IMPLICATIONS: Double continuous nerve blocks allow optimal analgesia in burned children after complex orthopedic surgery without major adverse events. Plasma concentrations of bupivacaine remained small during the study period.

Bupivacaine↗
PubMed2004

Small-dose intrathecal clonidine and isobaric bupivacaine for orthopedic surgery: a dose-response study.

We examined the dose-response relationship of intrathecal clonidine at small doses (<or=150 microg) with respect to prolonging bupivacaine spinal anesthesia. We aimed for establishing doses of intrathecal clonidine that would produce clinically relevant prolongation of spinal anesthesia and pain relief without significant side effects. Eighty orthopedic patients were randomly assigned to intrathecally receive isobaric 0.5% bupivacaine, 18 mg, plus saline (Group 1), clonidine 37.5 microg (Group 2), clonidine 75 microg (Group 3), and clonidine 150 microg (Group 4). Duration of the sensory block (regression below level L1) was increased in patients receiving intrathecal clonidine: 288 +/- 62 min (Group 1, control), 311 +/- 101 min in Group 2 (+8%), 325 +/- 69 min in Group 3 (+13%), and 337 +/- 78 min in Group 4 (+17%) (estimated parameter for dose 0.23 [95% confidence interval -0.05-0.50]). Duration of pain relief from intrathecal clonidine administration until the first request for supplemental analgesia was significantly prolonged: 295 +/- 80 min (Group 1, control), 343 +/- 75 min in Group 2 (+16%), 381 +/- 117 min in Group 3 (+29%), and 445 +/- 136 min in Group 4 (+51%) (estimated parameter for dose 1.02 [95% confidence interval 0.59-1.45]). Relative hemodynamic stability was maintained and there were no between-group differences in the sedation score. We conclude that small doses of intrathecal clonidine (<or=150 microg) significantly prolong the anesthetic and analgesic effects of bupivacaine in a dose-dependent manner and that 150 microg of clonidine seems to be the preferred dose, in terms of effect versus unwarranted side effects, when prolongation of spinal anesthesia is desired.

Adjuvants, Anesthesia↗
PubMed2005

Neuraxial anesthesia and low-molecular-weight heparin prophylaxis in major orthopedic surgery in the wake of the latest American Society of Regional Anesthesia guidelines.

In May 2003, the Second American Society of Regional Anesthesia Consensus Conference statement was issued partly in response to continued safety concerns over the use of regional anesthesia--in particular, neuraxial techniques--with low-molecular-weight heparin (LMWH) prophylaxis in major orthopedic surgery. As the 2003 Consensus statement makes clear, regional anesthesia may be used safely with LMWH prophylaxis. The key to optimizing patient safety, however, depends on a careful calibration of the total daily dose and the timing of the first and subsequent doses of the LMWH drug with the timing and management of the regional anesthetic procedure. Because the challenge of successfully providing regional anesthesia in the presence of LMWH thromboprophylaxis is a clinical one, anesthesiologists should do what they can to ensure that every member of the surgical team has an understanding of current literature and practice guidelines such as those recently published by the American Society of Regional Anesthesia.

Anesthesia, Conduction↗
PubMed2005

Antibiotic prophylaxis in orthopedic surgeries: the results of an implemented protocol.

Though the basic principles of antibiotic prophylaxis have been well established, there is still considerable incorrect usage, including how much is prescribed and especially in the duration of treatment, which is generally superior to what is indicated. The adequate use of these drugs contributes towards decreasing the time of internment of the patient, prevents surgical site infection (SSI), decreasing the development of resistant microorganisms, and towards reduced costs for the hospital pharmacy. A protocol for the use of antibiotic prophylaxis in the Orthopedics and Traumatology Service of the Hospital do Servidor Público Estadual de São Paulo was developed. The objectives of the study were to promote rational antibiotic surgical prophylaxis, through the implantation of a protocol for the use of these drugs in a surgical unit, with the direct contribution of a druggist in collaboration with the Infection Control Committee, to evaluate the adhesion of the health team to the protocol during three distinct periods (daily pre-protocol, early post-protocol and late post-protocol) and to define the consumption of antimicrobials used, measured as daily defined dose.

Antibiotic Prophylaxis↗
PubMed2005

Peripheral nerve blocks for perioperative management of patients having orthopedic surgery or trauma of the lower extremity.

Over the past decade several developments have lead to an increased interest in lower extremity PNBs including transient neurologic symptoms associated with spinal anesthesia, increased risk of epidural hematoma with the introduction of new antithromboembolic prophylaxis regimens, and evidence of improved rehabilitation outcome with continuous lower extremity PNBs. Simultaneously, the field of lower extremity blockade has been revolutionized through our better understanding of functional regional anesthesia anatomy, introduction of new drugs, better and more sophisticated equipment and wider teaching of lower extremity nerve block techniques. This review focuses on techniques and applications of lower extremity nerve blocks in patients having orthopedic surgery or trauma of the lower extremity, as well as potential complications and means to avoid them.

Anesthetics, Local↗
PubMed2005

Use of orthopedic finger distractor for facial asymmetry correction.

Facial asymmetry after unilateral ankylosis results due to the loss of the condylar growth center on the ankylosed side. This results in the skeletal midline deviating to the affected side, a lack of vertical growth on the same side produces a cant of the occlusal plane and mandibular retrognathism is seen as a result of the hypoplasia. The lower border of the mandibular corpus and angle on the contra lateral side is usually flattened. We report a case of facial asymmetry following unilateral ankylosis, which was treated by a combined approach with distraction osteogenesis and orthodontics. Inexpensive orthopedic finger distractors were used. The facial changes were analyzed using the Grummons facial asymmetry analysis.

Ankylosis↗
PubMed1981

Second consultant opinion for elective orthopedic surgery.

We abstracted records of 369 patients whose recommendations for elective orthopedic surgery were not confirmed by a second opinion consultant. Six months or more after the initial recommendation for surgery, 82 per cent had not had the operation performed, irrespective of the diagnosis and the characteristics of the physician recommending surgery. Reasons for consultant non-confirmation included: use of a cast, brace, or corrective footwear preferable (26.3 per cent), symptoms not severe enough (18.4 per cent), and physical therapy/exercises preferable (17.8 per cent).

Female↗
PubMed1987

Elective foot surgery: relative roles of doctors of podiatric medicine and orthopedic surgeons.

We examined the roles of Doctors of Podiatric Medicine (DPMs) and orthopedic surgeons in the provision of foot surgery by analyzing the 1982 computerized claims of over 1.1 million federal employees, retirees, and family members. We found that DPMs provided over 60 per cent of all elective insured foot surgery. Without being able to adjust for the severity of the patient's underlying condition or the appropriateness and outcome of the surgery, the average per procedure charge submitted by an orthopedist was 17 per cent higher than that of a DPM; orthopedists were five times as likely to perform a procedure on an inpatient basis, and admitted patients to a hospital had longer stays; DPMs perform a greater number of procedures per episode, but their overall charges during the average foot surgery episode were 30 per cent lower, primarily because of their lower hospitalization rates. The possible impact of recent changes in health care delivery on the DPM/orthopedist practice comparison are discussed as are several questions regarding the quality and need of the care provided by these two groups.

Aged↗
PubMed1993

The prevalence of internal orthopedic fixation devices in children in the United States, 1988.

This study provides the first estimated prevalence of implanted orthopedic fixation devices (e.g., pins or wires) among children in the United States, based on the Medical Device Implant Supplement to the 1988 National Health Interview Survey. The overall prevalence was 27 per 10,000 children younger than 18 years; prevalence was highest (59/10,000) among those aged 12 to 17 years. The lower extremities were the most frequent body site (43%) and injury was the leading specific reason for implantation (37%). Some (10%) were replacement implants.

Adolescent↗
PubMed2004

Pharmacoeconomic analysis of fondaparinux versus enoxaparin for the prevention of thromboembolic events in orthopedic surgery patients.

INTRODUCTION: Fondaparinux is a novel synthetic antithrombotic that has been evaluated for the prevention of venous thromboembolism (VTE). In four large trials in patients who underwent major hip or knee surgery, fondaparinux was found to have a good safety profile and be more effective than enoxaparin. To generate Canadian pharmacoeconomic data for fondaparinux, an internationally developed cohort deterministic model was used to estimate the costs and consequences of prophylaxis with fondaparinux compared with enoxaparin in the Canadian orthopedic surgical setting. DESIGN AND SETTING: A health economic advisory group was assembled to guide the pharmacoeconomic evaluation. Efficacy and safety data for fondaparinux relative to enoxaparin were abstracted from a meta-analysis of four randomized trials. Canadian cost data to populate the model were obtained from a resource-use survey of four large Canadian hospitals, from the Canadian Institute for Health Information (CIHI), and from the Canadian economic literature. Case-mix information obtained from CIHI was incorporated into the cohort deterministic model, which predicted the number of VTEs and bleeds following prophylaxis with fondaparinux or enoxaparin within 90 days of surgery, and the associated overall cost difference. The stability of the base-case findings was evaluated with sensitivity analyses. STUDY PERSPECTIVE: Canadian healthcare system perspective. MAIN OUTCOME MEASURES AND RESULTS: Assuming a case mix of 50,693 major hip or knee surgeries performed in Canada in 1999/2000 (as reported by CIHI), the model predicted that prophylaxis with fondaparinux would avoid an additional 16 symptomatic VTEs per 1000 patients over the first 90 days, with an average cost savings of Can 55 dollars per patient. These findings were stable when key economic and clinical parameters were varied, including bleeding events. CONCLUSIONS: Our results suggest that in Canada, prophylactic fondaparinux compared with enoxaparin avoids VTEs and is associated with lower costs in patients who undergo major hip or knee surgery.

Anticoagulants↗
PubMed1989

Delirium after elective orthopedic surgery: risk factors and natural history.

Forty-six orthopedic patients were studied to determine the incidence, natural history, and risk factors associated with post-operative delirium. Pre-operatively, patients were given a neuropsychological screening evaluation, the Mood Adjective Checklist (MACL), the Zung Depression Scale, the Anxiety Inventory Scale, and the Health Assessment Questionnaire (HAQ). A psychiatrist interviewed each patient on post-op day four for evidence of delirium as defined by DSM III criteria. Of the patients studied, thirteen (26%) were possibly or definitely delirious following surgery. Treatment with propranolol, scopolamine, or flurazepam (Dalmane) conferred a relative risk for delirium of 11.7 (p = 0.0028). Delirium was associated with increased post-operative complications (p = 0.01), poorer post-operative mood (p = 0.06), and an increase of about 1.5 days in length of stay (not significant). Delirious patients were significantly less likely than matched controls to improve in function at six months compared with a pre-operative baseline HAQ (t = 6.43, p less than 0.001).

Aged↗
PubMed2006

MRI appearance of myocutaneous flaps commonly used in orthopedic reconstructive surgery.

OBJECTIVE: Our aim was to describe the MRI appearance of myocutaneous flaps and to determine whether postoperative radiation therapy affects imaging. MATERIALS AND METHODS: We retrospectively reviewed 30 myocutaneous flaps in 27 patients (n = 165 examinations; mean, 6.1 examinations per patient). Examinations were analyzed for flap type, location, degree of atrophy, signal intensity, and enhancement. RESULTS: Sixty-three percent (19/30) of the flaps developed high T1-weighted signal (mean, 15 months); 83% (25/30) developed high T2-weighted signal (mean, 10 months). This occurred sooner in those patients with postoperative radiation therapy (9 vs 12 months). T2-weighted signal returned to baseline in 32% (8/25) of the flaps (mean, 21 months); this occurred sooner in flaps not exposed to postoperative radiation (10 months vs 38 months). Seventy-one percent (20/28) of the flaps enhanced greater than the background musculature. Enhancement was seen more frequently in patients treated with postoperative radiation therapy than those not treated with radiation (83% vs 63%). All flaps atrophied; however, the two functional latissimus dorsi flaps atrophied less. Although increased T2-weighted signal and enhancement were seen in flaps after postoperative radiation therapy as compared with those without, this was not significant (p = 0.35 and p = 0.40, respectively). CONCLUSION: Myocutaneous flaps used in orthopedic reconstructive surgery typically show increased signal intensity on T2-weighted images and contrast enhancement initially, followed by some degree of atrophy and increased signal intensity on T1-weighted images. Postoperative radiation therapy may increase the likelihood that the flap will exhibit increased T2-weighted signal and enhancement.

Adult↗
PubMed1996

Current sonographic applications in orthopedics.

Until recently, few orthopedic indications for sonographic imaging have been widely accepted. Advances in technology and concerns about imaging costs are expanding the role of sonography in musculoskeletal conditions. In this pictorial essay we review normal musculoskeletal sonographic anatomy, selected current applications, and potential pitfalls.

Humans↗
PubMedDate not supplied

[Psychopathologic reactions in orthopedic patients].

The idea to monitor and research psychopathological responses of physically injured persons in a more systematic manner has come from our observation of huge differences in patient behavior, whose psychological responses were noticeably changed and often inappropriate. The behavior aberrations were all the more striking because we treated war-time injuries in addition to peacetime ones. Our sample had 175 patient subjects, of both sexes, different ages, marital status and professions. A group of 70 patients treated in the Institute for Orthopedic Surgery and Traumatology were divided into two subgroups. The first experimental subgroup (E1) consisted of 26 (37.1%) patients physically injured in combat. The second subgroup (E2) had 44 (62.9%) patients physically injured in peacetime circumstances (car accidents, work accidents, etc). The physical injuries encompassed injuries to spinal column and extremities. The control (K) consisted of 105 subjects without physical injuries. The clinical picture and psychological reactions of the patients were examined by means of 4 instruments--PTSD-10 scale or posttraumatic symptoms scale [1], Family Homogeneity Index/FHI/with 19 variables, applied to measure the relation between the family system homogeneity and accident effects [2], Short Eysenck's Personality Inventory applied to investigate neuroticism and extroversion and introversion traits [3], Late Effects of Accidental Injury Questionnaire [4]. Our observations of psychological responses of patients in our ward (insomnia, sedatives intake) were mostly confirmed by tests conducted with the above instruments. In the group of the wartime injured (E1), as well as in the control (K), Eysenck's scale proved a significantly higher degree of neuroticism in comparison to the peacetime injured. Such results indicated that the wartime injured would most probably develop the picture of Posttraumatic Stress Disorder. Such a conclusion was related not only to the seriousness of injuries but also to the circumstances of their occurrence. The proneness to develop PTSD symptoms was not in correlation with the preparedness for accident, it being much poorer in peace-time injuries, as opposed to wartime patients, who had been prepared to the possibility of injury occurrence. The highest value of family homogeneity (FHI) was established in the wartime injured, which led us to conclude that the injury contributed to the cohesion of the family from which the patient came. By extracting some questions related to psychopathological entities such as insomnia, depression, somatization, anxiety, and cognitive disorders, the following results were obtained. Depression was the most frequent in both groups of injuries. Anxiety was also present in the control group; and insomnia and somatization, that is, conversion symptoms, were present in both groups of the injured. By examining narrower psychological characteristics of the wartime injured revealed dissociation problems--derangement to be the most frequent. Then follow the symptoms of depression, which occur significantly more frequently in the wartime injured in comparison to the peacetime injured. The phenomenological symptoms of derangement and depression proved to be reliable parameters of physical trauma. It is also significant that the three characteristics showed correlation to psychopathological responses: severity of surgery, paralysis, and acute injury.

Accidents↗
PubMedDate not supplied

Our experience with orthopedic surgery in hemophiliacs.

INTRODUCTION: Patients having severe hemophilia (levels of deficient factor below 1%) frequently suffer from disabling chronic arthropathy. An adequate substitution treatment using the coagulation factor VIII or IX concentrates renders an elective surgery feasible. OBJECTIVE: The objective of the study was to check the results of different surgical procedures in the treatment of hemophilic arthropathies, and to propose the best protocol of their treatment. METHODS: This is a retrospective study on 26 hemophilic patients operated in the Orthopedics and Trauma Clinic II, Timişoara, from 2002 to 2005. Elective surgical procedures were mainly performed in the knee (21 arthroscopic procedures, 1 open arthrodesis), elbow (2 open synovectomies, 2 radial head excisions), ankle (1 arthroscopic synovectomy and debridement) and thigh (1 giant pseudo tumor excision, other minor procedures). The results after operations on moderate and severe chronic knee, elbow and ankle arthropathy were evaluated, with approximately 24-month follow-up period. RESULTS: Arthroscopic procedures (22) yielded good and satisfactory results with significant improvement according to the evaluation criteria recommended by the World Hemophilia Federation (Gilbert clinical score, Pettersson radiological score, Nuss MRI score). CONCLUSION: Mini-invasive elective surgery in moderate to severe chronic arthropathy produces good results when performed in a specialized centre and with multi-disciplinary approach.

Adolescent↗
PubMed1992

Addressing the psychosocial needs of orthopedic pain patients.

Analysis of comprehensive examinations of 258 patients with orthopedic pain yielded 5 types of pain responders. Research is under way to analyze the response to pain and effectiveness of response treatment for each type of pain responder.

Adaptation, Psychological↗
PubMed1983

Early bone grafting in complete cleft lip and palate cases following maxillofacial orthopedics. VI. Assessments from photographs and anthropometric measurements.

The superficial facial topography of children born with complete unilateral or bilateral cleft lip and palate was studied with anthropometry and subjective assessments of standardized photographs. All the children had been bone grafted early with Nordin's "four-flap" technique. The unilateral deformities group comprised two sub-groups: one of 39 children (mean age 17.6 years) primarily operated without preoperative orthopedics, and another of 46 children (mean age 10.8 years) primarily operated after preoperative "T-traction" The bilateral group, 19 children (mean age 15.1 years) was primarily operated after preoperative premaxillary retropositioning pressure, if necessary, combined with outward rotation of the lateral maxillary segments. The groups were compared with each other and then in the anthropometric study with nonclefts. With 14 expert observers the subjective assessment method was found to be useful when comparing groups of children. When comparing the two unilateral groups, the "T-traction" group showed a straighter and more normal nose and less difference in sagittal and vertical directions between the levels of the alar bases. Overall facial features scored closer to normals than did those of the non-traction group. On comparing the unilateral groups with nonclefts our findings for several variables corresponded to what was found by others earlier. The width of the mouth was narrower in unilateral clefts than in nonclefts. Unlike that reported by others, our unilateral cleft sample had shorter medial vertical upper lip length and shorter and broader noses than nonclefts.

Adolescent↗
PubMed1996

Stability of trypsin immobilized on inorganic orthopedic biomaterials.

Biochemical surface modification of biomaterials utilizes immobilized biomolecules to induce preferred tissue responses. Although several techniques are available for immobilizing biomolecules on organic substrates, comparatively few are available for use with inorganic materials, such as those used in many orthopedic applications. The present study investigated the stability/elutability of a model enzyme immobilized on Co-Cr-Mo and Ti-6Al-4V alloys using p-nitrophenyl chloroformate (p-NPC). Trypsin-conjugated biomaterials were incubated in cell culture medium at 37 degrees C for up to 96 hr, and the residual immobilized activity was measured. Although all samples initially bound enzymatically active trypsin, significant decreases were observed within the first 2 hr of incubation. Immobilization of trypsin on Co-Cr-Mo treated with 0.65 mg p-NPC/cm2 of nominal surface area gave significantly higher residual activity than on untreated samples at 24-96 hr of incubation and prevented the nearly complete loss of enzymatic activity that was observed with free (not immobilized) enzyme. Derivatization of Ti-6Al-4V with p-NPC was not beneficial to the level of immobilized enzymatic activity after incubation in medium for longer than 6 hr.

Alloys↗