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Traditionally one of hospitals' most lucrative service lines, orthopedics is under pressure these days, as federal reimbursement policies make certain procedures less profitable and hospitals face new challenges from physicians. It remains a strong market to court, but hospitals are increasingly seeking to protect, rather than expand, their business.
Taking the institution of a new Hospital as a hint, the author underlines the need for the newly realized Hospitals to be planned, equipped and organized in a rational way so that they may offer a "quality leap" in the sanitary assistance raising it to the levels already reached in other Countries. For this purpose some planning devices and technical innovations are to be suggested (in services of medical interest) which aim at making the stay in hospital of an orthopedic-traumatologic patient more advantageous. Next to the constructive solutions, passive, it is necessary to underline the utility of the stay in hospital to become "active". With this term the author means both the way of conceiving the stay in hospital, characterized by the so-called "bed physical exercises", organized by a "ward physioterapist", and a real "active" participation of a patient in the life of the ward in its daily aspects even the smallest ones.
Experience of application of laryngeal mask (LM) for realization of artificial pulmonary ventilation in patients in complicated conditions for trachea intubation in orthopedic surgery allows to recommend it as an alternative method. Simplicity of establishment, absence of complications after application of LM were noted.
A small experimental study on rats in orthopedics shows that it is impossible to achieve constant bipedy as a basis for valid static and biomechanic investigations, particularly of the spine.
Orthopedic deformities in the lower limb concern all joints (hip, knee, ankle, foot) with a wide range of clinical forms. Spasticity, contracture, stiffness, laxity, neurological deficit are assessed to establish the surgical procedure. Surgical techniques are adapted to the goals that are detailed with the patient and his family: standing, transferring, walking, hygiene, devices (shoes, orthosis, canes, wheelchair). Surgical procedures can associate: lengthening of contractured muscles (tenotomy with or without sutures, fractional lengthening at the musculo-tendinous junction or desinsertion), strengthening of antagonists (passive or active tendon transfer) and correction of joint deformity (arthrolysis, arthrodesis, arthroplasty). In adults, the most common deformities are the equinus or equinovarus foot, toe curling, hip adductum, knee flessum. Talus or knee recurvatum are less frequently observed. The association of various deformities raises questions concerning the hierarchy of surgical procedure, from an anatomical point of view (do we start with proximal or distal joint first?) as from chronological concerns (shall we do one or more procedures?). Pluridisciplinary assessment using neurological anesthetic blocs and dynamic EMG or gait analysis is necessary to detail the aims of surgery and choose the surgical procedures.
Orthopedic surgery for upper extremity spasticity is based on a precise clinical evaluation with motor and sensitive and cognitive factors. Use of electromyography and lidocain or toxin is necessary. Surgical aims are classified as hygienic or functional. Surgical procedures are divided into neurectomies, muscle, tendon and joint procedures. Results, in spite of heterogeneous populations and nonstandardized assessments, are described about shoulder, elbow and hand.
Patients undergoing autologous donation prior to elective orthopedic surgery show better Hb values during the perioperative period compared to those without autologous donation, all patients in both groups receiving no homologous transfusion. The widely assumed improvement of Hb regeneration during the postoperative period according to an erythropoiesis stimulated by preoperative autologous donation is not supported by our data.
There are many diverse opinions regarding thromboprophylaxis in orthopedics. Symptomatic events are relatively rare, but the mortality and morbidity rates of patients demand an attempt to reduce the risk. However, the costs and risks of these attempts must be balanced against the efficacy. Until recently, the simplest and most effective chemical prophylactic method has been low molecular weight heparin, which should be continued for at least 5 weeks after surgery. Recent data show that pentasaccharide is more effective. Chemical agents should be used carefully to avoid bleeding into the surgical wound and spinal cord. Mechanical methods, such as the A-V Impulse Foot Pump (Novamedix, Andover, Hampshire, UK), offer a safe and effective alternative, which is attractive in the perioperative period and could be used as an additional method in patients at high risk of thrombosis. In the future, oral antithrombin agents may offer a practical and effective solution to extended duration prophylaxis.
OBJECTIVES AND METHODS: A retrospective, modeled, cost-effectiveness analysis was conducted with enoxaparin versus non-prophylaxis, tinzaparin, and unfractionated heparin for venous thromboembolic disease in Spanish patients undergoing major orthopedic surgery from the standpoint of the Spanish national health system. Episodes avoided and life-years gained with each treatment were estimated by a meta-analysis of clinical trials. RESULTS: With enoxaparin fewer thromboembolic episodes and deaths occurred, when compared to the available alternative options. Enoxaparin was the dominant option (lower total cost and equal or greater effectiveness than any alternative option) in comparison with non-prophylaxis, tinzaparin, and unfractionated heparin. A sensitivity analysis confirmed the stability of these results. CONCLUSION: The administration of enoxaparin as a prophylactic treatment for venous thromboembolic disease in patients undergoing hip or knee surgery is a cost-effective intervention in every case, and less expensive than the alternative options used in Spain.
In a short-term comparison of similar pediatric orthopedic practices at a military and a civilian institution in the same geographical location, it was found that total appointment time, waiting time, and travel time were longer in the military setting. It appeared, however, that there was more leniency toward time off from work to accompany children to appointments in the military population. These factors may have considerable impact on time lost from the job for service member sponsors.
Advancements in general medicine and anesthesiology have enabled surgical procedures in old people with diminished risks. With reference to special problems the absolute indication for orthopedic procedures particularly for the old can be demonstrated.
OBJECTIVES: The accuracy of references was assessed in Turkish journals of orthopedics and traumatology. METHODS: All references cited in four journals (Acta Orthopaedica et Traumatologica Turcica, Arthroplasty Arthroscopic Surgery, Hacettepe Journal of Orthopaedic Surgery, and The Journal of Turkish Spinal Surgery) throughout 1995 to 1999 were numbered consecutively. One percent of references from each journal was randomly selected to be evaluated in comparison with primary sources. Errors were classified in three categories. Another randomized selection was made to check 50 references from each journal. The results were assessed by the t-test. RESULTS: Of 18,193 references cited in four journals, 182 references were checked. Errors were found in 117 references (63%), seven of which were major errors that prevented location of the primary source. When 50 references were checked from each journal, the mean inaccuracy rate was 60%. No significant differences were found between the journals with respect to the frequency of erroneous references. CONCLUSION: The high rate of inaccuracy emphasizes the need for greater care in the use of references on the part of authors, journal editors, and reviewers.
PURPOSE OF THE STUDY: Surveillance of nosocomial surgical site infections was instituted in our department in June 1991. We report our first nine years experience. MATERIAL AND METHODS: This study concerned the first 9 years (June 1991-June 2000) of a surveillance program designed to monitor nosocomial surgical site infections in our orthopedic surgery department. During this period 9,696 patients underwent surgery, including 2745 for hip replacements and 1016 for knee replacements. The diagnosis of infection was based on the Centers of Disease Control criteria. Beginning in 1997, the program was widened to include all indications for prophylactic antibiotics, being limited before that time to indications for arthroplasty and spinal surgery. RESULTS: The overall rate of infection was 1.25%; 0.55% for hip arthroplasty and 1.77% for knee arthroplasty. The rate of infection among hip surgery patients over the last 5 years was much higher for prosthesis revision (2.37%) than for first-intention implantations (0.16%). The majority of the isolated strains were Gram-positive (84%) including Staphylococcus sp. found in 65% of the cases. Multiple-strains were found in 23% of the infections. The rate of infection improved very significantly over the last five years both for knee arthroplasty and spinal surgery. The rate remained unchanged for hip arthroplasty. DISCUSSION: This 10-year survey enabled us to analyze the difficulties encountered and pinpoint errors or insufficiencies in data recording. We were also able to identify measures to be taken concerning patient follow-up. The improvement in the rate of infection over time appears to be multifactorial, undoubtedly related to wider use of prophylactic antibiotics, progress in hygiene and sterilization methods with institution of a quality assurance program, and team awareness. CONCLUSION: Surveillance of nosocomial infections is a recommended practice. We have found that the information provided can be beneficial if the data is statistically sound, pointing out the need for progress in patient follow-up.
BACKGROUND: Patients with anemia undergoing elective joint replacement are often excluded from preoperative autologous donation (PAD). The purpose of this study was to compare the efficacy of preoperative erythropoietin (epoetin alpha) as an adjuvant treatment to PAD versus preoperative erythropoietin alfa alone in patients with mild anemia undergoing major orthopedic surgery. PATIENTS AND METHODS: The study enrolled 75 patients scheduled for total joint arthropalsty of the hip or knee or spinal surgery and with a hemoglobin (Hb) concentration between 10 and 13 g/dL. Group 1 patients were assigned to receive weekly doses of subcutaneous epoetin alpha (40,000 IU) 21, 14, and 7 days before surgery and to participate in the PAD program; group 2 patients were excluded from the PAD program and received 2 doses of epoetin alpha every week over the same period. RESULTS: Group 1 (n = 39) and group 2 (n = 36) were similar with respect to patient characteristics, biological parameters, and surgical procedures, In group 1, mean preoperative Hb rose fom 12.5 g/dL to 12.8 g/dL, patients received a mean 5.1 doses of epoetin alpha, and they gave a mean 1.9 units of autologus blood and 1 received allogenic blood. In group 30.7% received transfusions of autologous blood and 1 received allogenic blood. In group 2, preoperative Hb increased from 11.7 g/dL to 13.5 g/dL, patients received 3.8 doses of epoetin alpha, and 3 were transfused with allogenic blood (P > 0.05). CONCLUSION: Epoetin alpha alone and erythropoietin as a adjuvant to a PAD program are equally effective in reducing allogenic transfusion during hip and knee arthroplasty and spinal column surgery of up to 3 spaces.
OBJECTIVE: To determine the usefulness of double gloves in protecting against the exposure of surgical team members' hands to blood. METHODOLOGY: Five-hundred-ninety-six gloves were studied during 71 orthopedic operations using the water-loading test (filling a glove with water and occluding its cuff tightly to identify leaking points). RESULTS: In all, 73 glove perforations occurred, but only nine resulted in exposure to blood (blood touching the skin). The incidence of glove perforation was 12% (73/596), and overall exposure (blood touching the skin) per operation was 13% (9/71). The latter would have been 87% (62/71) but for the use of double gloves. Sixteen percent of the perforations in double gloves were in the inner gloves, while 84% were in the outer gloves. Exposure of surgeons was reduced from 54% to 10%, first assistants from 27% to 3%, and second assistants from 7% to 0 (p < 0.02, df = 2) by double-gloving. Significantly more perforations occurred during operations on bone, compared with soft tissue operations, p < 0.0001, RR = 4 (95% CL 1.87-8.55). The most common sites of glove perforation were the index finger (47%), thumb, and the palm region: 14% each. More glove perforations occurred in nondominant hands. CONCLUSION: Double-gloving offers additional protection to surgeons and assistants by preventing hand exposure to blood intraoperatively.
In order to use etiopathogenetic criteria for the treatment of postsurgical pain, non-steroid anti-inflammatory drugs (NSAIDs) can be used rather than narcotic analgesics. These agents are often classified as peripherally acting analgesic drugs; nevertheless in the last years many pages have who showed a central supraspinal analgesic effect. Sodium naproxen is commonly used in the treatment of postoperative orthopedic pain because of its pharmacokinetic properties. The aim of this study was to evaluate the suitable dosage of sodium naproxen for post-surgical pain relief. Forty patients submitted to foot surgery were randomized into two groups of 20 patients each. At the end of surgery one group of patients (group I) received sodium naproxen 275 mg i.m.; the same dose was administered after 12 hours. A second group (group II) received sodium naproxen 550 mg i.m. at the same time intervals. Based on a Descriptive scale for algometric measurements, the results showed significant differences in analgesic activity for the two treatments. The best results (70% of patients with no pain or slight pain vs 20% of patients) were obtained in the group that received sodium naproxen at the higher dosage (p less than 0.001). No differences were observed in the incidence of side-effects in the two groups. These results are discussed.
OBJECTIVES: The aim of the study was to prospectively evaluate the results of continuous intradural anesthesia with 18G Tuohy needle and 20G catheter in geriatric patients. MATERIAL AND METHODS: We studied 70 patients with a mean age of 75.9 +/- 10.8 years who were subjected to orthopedic or traumatologic surgery of the lower extremities with a duration of 104.6 +/- 53.6 min. RESULTS: Success index was 95.7%. The initial dose of 1% tetracaine was 10.36 +/- 3.96 mg, the second dose in 29 patients was 7.2 +/- 2.7 mg, the third in 7 cases was 7.40 +/- 2.47 mg, and the total dose was 14.56 +/- 5.6 mg. The metameric level was between T8 and T11 in 80.32% of patients. Peroperative complications were limited to paresthesia in 5 cases (7.14%) during insertion of the catheter, difficulties in catheter placement in one case (1.42%), and accidental catheter extraction during withdrawal of the needle in 2 cases (2.85%). Ten patients (14.28%) presented arterial hypotension (pressure decrease greater than 30% of baseline systolic arterial pressure). During the postoperative phase there were 3 cases of slight headache after dural puncture (4.28%) that recovered with conservative treatment, and one case of lumbalgia at the puncture zone (1.42%). CONCLUSIONS: Continuous intradural anesthesia with the material used in this study is technically easy. It allows to accurately reach the desired metameric level, avoiding massive sympathetic blockade, and providing a steady hemodynamic condition. All these effects are essential for anesthesia in geriatric patients.
The use of new promising materials for implanting elements in traumatology and orthopedics is under discussion in the paper. Steel pins coated with zirconium do not cause any inflammatory complications when applied. The initial results of using the zirconium-coated implants offer the challenge for using such devices in future.