Modhia, UM; Dickens, AJ; Glezos, CD; Gehlert, RJ; DeCoster, TA
Background The OTA Fracture Classification is designed to provide a common language and facilitate effective communication among orthopaedic surgeons. We attempted to measure the degree to which this classification is currently being utilized in orthopaedic trauma literature. Methods We reviewed all of the articles in the JOT in 2011. We determined which of these articles could have appropriately utilized the 2007 OTA Classification. We calculated the percentage that mentioned and correctly cited this classification system as a reference. Results There were 145 articles in 2011. One hundred of these articles were appropriate for classifying a fracture. 38% of these articles utilized the OTA classification in the text. Only 42% of articles mentioning the OTA Classification cited a reference. 38% of these citations used the old (1996) OTA Classification reference, and only 8% overall correctly cited the 2007 OTA Classification reference. 51% of articles mentioned some other classification system; 21 in addition to OTA and 30 instead of the OTA classification. Conclusions The OTA Fracture Classification is being used more commonly (38%) but is not routinely used or correctly cited (8%) in articles currently being published in the Journal of Orthopaedic Trauma, despite the fact that it is “required” according to the instructions to authors. We conclude that future authors should utilize and correctly reference the 2007 OTA Classification so that the benefits of a common language can be realized. Routine and consistent utilization of the classification may ultimately lead to more consistency and improved interpretability of treatment outcomes in published orthopaedic trauma research. Level of Evidence Level-III case-control study, decision analysis PMID:25328459
Hake, Mark E; Young, Heather; Hak, David J; Stahel, Philip F; Hammerberg, E Mark; Mauffrey, Cyril
The use of local antibiotics for the prevention of infection in the setting of open fractures and as part of the treatment of osteomyelitis is well established. Antibiotics are most commonly incorporated into polymethylmethacrylate (PMMA) cement, which can then be formed into beads, moulded to fit a bone defect or used to coat a guide wire or IM nail. Newer delivery vehicles and techniques are being evaluated to improve upon these methods. Many factors influence how local antibiotics are applied. Treatment strategies are challenging to standardise due to the variability of clinical presentations. The presence of hardware, upper versus lower extremity, healed versus non-healed fracture and quality of soft tissues overlying the affected bone, as well as patients' comorbidities all need to be considered. Despite the accepted use of local antibiotic therapy in orthopaedic trauma, high-quality evidence regarding the use of local antibiotics is lacking. Indications, techniques, dosages, types of antibiotics, elution properties and pharmacokinetics are poorly defined in the clinical setting. The purpose of our manuscript is to review current strategies and provide practical tips for local application of antibiotics in orthopaedic trauma. We focus on delivery vehicles, types of antibiotics, dosage recommendations when mixed with PMMA and indications.
Held, M; Engelmann, E; Dunn, R; Ahmad, S S; Laubscher, M; Keel, M J B; Maqungo, S; Hoppe, S
A growing burden of gunshot injuries demands evidence-based ballistic trauma management. No comprehensive systematic overview of the current knowledge is available to date. This study aims to identify and analyze the most influential publications in the field of orthopedic ballistic trauma research. All databases available in the Thomson Reuters Web of Knowledge were searched to conduct this bibliometrical study. The most cited orthopedic ballistic trauma articles published between 1950 and 2015 were identified by use of a multi-step approach. Publications with ten citations and more were analyzed for citations, journal, authorship, geographic origin, area of research, anatomical site, study type, study category, and level of evidence. Citations of the 128 included studies ranged from 113 to 10. These were published in fifty different journals between 1953 and 2011. Most publications (n=106; 83%) originated from the USA, were retrospective (n=85; 66.4%), level IV studies (n=90; 70.3%), reported on spinal gunshot injuries (n=49; 38.33%) and were published between 1980 and 2000 (n=111; 86.7%). This bibliometric study provides the first comprehensive overview of influential publications in the field of orthopedic ballistic trauma research. More prospective studies and high-quality systematic reviews are needed. Centres with a high burden of gunshot injuries from the developing world need to share their experience in form of international publications, to provide a more comprehensive picture of the global gun-related orthopedic injury burden. bibliometric analysis: level III. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
Beringer, Antonia; Hagan, Liz; Goodman, Hannah
Nursing staff on a paediatric surgical ward were concerned about delays experienced by children waiting to go to theatre following orthopaedic trauma, and their families. A facilitated action research approach was used which involved describing the issue, gathering information from a range of sources and introducing changes to the process of care. A flowchart was developed to clarify the stages and the staff involved in admitting a child with orthopaedic trauma for surgery. A white board was introduced to record information on 'trauma' patients. A facilitated action research process offers a flexible and accessible way for staff to develop a range of transferable research and change management skills.
Mir, Hassan R
Incorporating research into practice as an orthopaedic trauma surgeon can be very fulfilling. There are challenges when getting started whether in a university or other practice setting. Understanding the various components of the research process is important before beginning and thereafter. This article reviews some of the issues that may be encountered and strategies to help.
O'Hara, Nathan N.; Mugarura, Rodney; Slobogean, Gerard P.; Bouchard, Maryse
The disability adjusted life years (DALYs) associated with injuries have increased by 34% from 1990 to 2010, making it the 10th leading cause of disability worldwide, with most of the burden affecting low-income countries. Although disability from injuries is often preventable, limited access to essential surgical services contributes to these increasing DALY rates. Similar to many other low- and middle-income countries (LMIC), Uganda is plagued by a growing volume of traumatic injuries. The aim of this study is to explore the orthopaedic trauma patient's experience in accessing medical care in Uganda and what affects the injury might have on the socioeconomic status for the patient and their dependents. We also evaluate the factors that impact an individual's ability to access an appropriate treatment facility for their traumatic injury. Semi-structured interviews were conducted with patients 18 year of age or older admitted with a fractured tibia or femur at Mulago National Referral Hospital in Kampala, Uganda. As limited literature exists on the socioeconomic impacts of disability from trauma, we designed a descriptive qualitative case study, using thematic analysis, to extract unique information for which little has been previously been documented. This methodology is subject to less bias than other qualitative methods as it imposes fewer preconceptions. Data analysis of the patient interviews (n = 35) produced over one hundred codes, nine sub-themes and three overarching themes. The three overarching categories revealed by the data were: 1) the importance of social supports; 2) the impact of and on economic resources; and 3) navigating the healthcare system. Limited resources to fund the treatment of orthopaedic trauma patients in Uganda leads to reliance of patients on their friends, family, and hospital connections, and a tremendous economic burden that falls on the patient and their dependents. PMID:25360815
Greenberg, Sarah; Mir, Hassan R; Jahangir, A Alex; Mehta, Samir; Sethi, Manish K
Traumatic injury, which remains the leading cause of death for Americans aged 1 to 44 years, costs the United States over $400 billion because of loss of productivity and medical services each year. Yet, over the last few decades, there has been decreased funding for trauma centers. The 2010 Affordable Care Act is just the start of health care reform, and Congress will continue to create and change policies directly impacting medical care. In this article, we evaluate how orthopaedic trauma surgeons can have a lasting impact on the nation's health care policy through organizations and advocacy on the local, state, and federal levels.
Althausen, Peter L; Bray, Timothy J; Hill, Austin D
The Reno Orthopaedic Center (ROC) Trauma Fellowship business curriculum is designed to provide the fellow with a graduate level business practicum and research experience. The time commitments in a typical 12-month trauma fellowship are significant, rendering a traditional didactic master's in business administration difficult to complete during this short time. An organized, structured, practical business education can provide the trauma leaders of tomorrow with the knowledge and experience required to effectively navigate the convoluted and constantly changing healthcare system. The underlying principle throughout the curriculum is to provide the fellow with the practical knowledge to participate in cost-efficient improvements in healthcare delivery. Through the ROC Trauma Fellowship business curriculum, the fellow will learn that delivering healthcare in a manner that provides better outcomes for equal or lower costs is not only possible but a professional and ethical responsibility. However, instilling these values without providing actionable knowledge and programs would be insufficient and ineffective. For this reason, the core of the curriculum is based on individual teaching sessions with a wide array of hospital and private practice administrators. In addition, each section is equipped with a suggested reading list to maximize the learning experience. Upon completion of the curriculum, the fellow should be able to: (1) Participate in strategic planning at both the hospital and practice level based on analysis of financial and clinical data, (2) Understand the function of healthcare systems at both a macro and micro level, (3) Possess the knowledge and skills to be strong leaders and effective communicators in the business lexicon of healthcare, (4) Be a partner and innovator in the improvement of the delivery of orthopaedic services, (5) Combine scientific and strategic viewpoints to provide an evidence-based strategy for improving quality of care in a
Metcalfe, David; Olufajo, Olubode A; Zogg, Cheryl K; Rios-Diaz, Arturo; Harris, Mitchel; Weaver, Michael J; Haider, Adil H; Salim, Ali
30-day readmission is increasingly used as a hospital quality metric. The objective of this study was to describe the patient factors associated with unplanned 30-day hospital readmission of orthopaedic trauma patients. A statewide observational study was undertaken using data from all acute hospitals in California. All hospital inpatients with a primary diagnosis of fracture or dislocation (ICD-9-CM codes 800-829) were included, except for those with isolated injuries to the skull, face, or ribs. The primary outcome measure was unplanned 30-day readmission to any hospital in California. 416,568 trauma admissions were available for analysis. The overall readmission rate was 6.5%, and 27.3% of readmitted patients presented to a different hospital. Factors significantly associated with readmission were male sex (OR 1.23, 95% CI 1.19-1.27), age 46-65 (2.61 [2.27-2.99]), black race (1.19 [1.11-1.27]), entitlement to publicly funded healthcare (1.38 [1.25-1.52]), Charlson Comorbidity Index ≥2 (1.84 [1.79-1.90]), discharge against medical advice (3.13 [2.67-3.68]), and spinal fracture (1.42 [1.34-1.49]). Major reasons for readmission included: cardiopulmonary disease (25.6%), infections (20.1%), musculoskeletal problems (18.1%), and procedural complications (12.0%). Many orthopaedic trauma readmissions are potentially unrelated to the initial hospitalization. Penalties for unplanned readmissions risk penalizing hospitals that serve disadvantaged communities and treat a high proportion of trauma patients. Copyright © 2016 Elsevier Ltd. All rights reserved.
Harris, Mitchel B
Massachusetts was the first state to implement its own version of the Affordable Care Act (ACA), when it passed the Massachusetts Health Care Reform (MHR) in 2006. Similar to the ACA, its explicit purpose was universal access to health care to all residents of Massachusetts. We believe that the influence of MHR on orthopaedic trauma in Massachusetts will have implications on trauma systems across the country, given the similarities between ACA and MHR. Therefore, in this article, we discuss our experiences as Orthopaedic trauma surgeons with regard to MHR. In this regard, we reviewed the effects of the implementation of MHR on the orthopaedic trauma services at 3 of the 4 level one trauma centers in Boston, MA. Our results demonstrate a dramatic reduction in the proportion of uncompensated care at these centers in addition to the number of uninsured patients with orthopaedic trauma injuries.
Agarwal-Harding, Kiran J; von Keudell, Arvind; Zirkle, Lewis G; Meara, John G; Dyer, George S M
➤The burden of musculoskeletal trauma is high worldwide, disproportionately affecting the poor, who have the least access to quality orthopaedic trauma care.➤Orthopaedic trauma care is essential, and must be a priority in the horizontal development of global health systems.➤The education of surgeons, nonphysician clinicians, and ancillary staff in low and middle income countries is central to improving access to and quality of care.➤Volunteer surgical missions from rich countries can sustainably expand and strengthen orthopaedic trauma care only when they serve a local need and build local capacity.➤Innovative business models may help to pay for care of the poor. Examples include reducing costs through process improvements and cross-subsidizing from profitable high-volume activities.➤Resource-poor settings may foster innovations in devices or systems with universal applicability in orthopaedics. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.
Mamczak, Christiaan N; Streubel, Philipp N; Gardner, Michael J; Ricci, William M
The increasing frequency of orthopaedic trauma patient transfers is an issue at the centre of the current orthopaedic "call crisis" that has the potential to inundate resources at tertiary care centres. Appropriateness of transfer has been investigated only from the perspective of receiving surgeons. This study investigates the suitability and reasons for orthopaedic trauma patient transfer from the viewpoint of transferring surgeons. A questionnaire was e-mailed to a random sampling of 500 active members of the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association. Surgeons were split into three groups: senders of trauma patients (senders); orthopaedic traumatologists who receive transfers (traumatologist receivers); and other trauma transfer receivers that are not traumatologists (non-traumatologist receivers). The perceived complexity and appropriateness for transfer of eight virtual case scenarios were determined, along with the specific reasons mitigating transfer. 51 Senders, 90 traumatologist receivers, and 98 non-traumatologist receivers completed 239 surveys. There was agreement between groups for case complexity and appropriateness for transfer in five of eight case scenarios (p<0.05). Fracture complexity was cited as the primary reason for transfer by 28% of senders. However, just as common was a lack of resources at the sending hospital; OR equipment (18%), critical care services (18%), and inability to handle the immediacy of the case (7%) were also cited. Likelihood of uninsured status was the least common reason for transfer (1%). In most cases, both senders and receivers of orthopaedic trauma have similar viewpoints regarding fracture complexity and appropriateness of transfer. Sending surgeons cite case complexity and a lack of hospital resources as the primary reasons for patient transfer. Mandating increased call for orthopaedic surgeons at non-trauma centres without a concomitant increase in hospital resources is
Slobogean, Gerard P; Dielwart, Cassandra; Johal, Herman S; Shantz, Jesse A S; Mulpuri, Kishore
To examine the strength of evidence presented at the Orthopaedic Trauma Association (OTA) annual meetings before and after the level of evidence guidelines became popular in the literature. 10 years of abstracts from OTA podium presentations, preguidelines (1998-2002), and postguidelines (2007-2011). All abstracts were blinded and randomized for review. Only therapeutic, diagnostic, prognostic, and economic study types were included. Study type and level of evidence were determined for each abstract. Five hundred thirteen abstracts were included, primarily consisting of therapeutic studies (63%). The distribution of study types between the pre- and postguideline periods was similar (P = 0.37). The levels of evidence for podium presentations in the preguideline period were as follows: level I, 10%; level II, 16%; level III, 14%; and level IV, 60%. The distribution in the postguideline period was as follows: level I, 13%; level II, 2%; level III, 29%; and level IV, 36%. The differences between the pre- and postguideline presentations were significant (P < 0.0001), indicating an improvement in the strength of evidence presented at the annual meetings. The majority of podium presentations at the OTA annual meetings are level IV studies; however, there has been a measurable decrease in the number of uncontrolled case series presented at more recent meetings. Encouraging reporting of levels of evidence at future annual meetings has the potential to positively influence the orthopaedic trauma community by improving readers' understanding of the strength of evidence presented, the study design hierarchy, and encouraging investigators to conduct controlled study designs when possible.
Nousiainen, M T; McQueen, S A; Hall, J; Kraemer, W; Ferguson, P; Marsh, J L; Reznick, R R; Reed, M R; Sonnadara, R
As residency training programmes around the globe move towards competency-based medical education (CBME), there is a need to review current teaching and assessment practices as they relate to education in orthopaedic trauma. Assessment is the cornerstone of CBME, as it not only helps to determine when a trainee is fit to practice independently, but it also provides feedback on performance and guides the development of competence. Although a standardised core knowledge base for trauma care has been developed by the leading national accreditation bodies and international agencies that teach and perform research in orthopaedic trauma, educators have not yet established optimal methods for assessing trainees' performance in managing orthopaedic trauma patients. This review describes the existing knowledge from the literature on assessment in orthopaedic trauma and highlights initiatives that have recently been undertaken towards CBME in the United Kingdom, Canada and the United States. In order to support a CBME approach, programmes need to improve the frequency and quality of assessments and improve on current formative and summative feedback techniques in order to enhance resident education in orthopaedic trauma. Cite this article: Bone Joint J 2016;98-B:1320-5. ©2016 The British Editorial Society of Bone & Joint Surgery.
Lohmann, C H; Hameister, R; Singh, G
Hypersensitivity reactions to implants in orthopaedic and trauma surgery are a rare but devastating complication. They are considered as a delayed-type of hypersensitivity reaction (type IV), characterized by an antigen activation of sensitized T-lymphocytes releasing various cytokines and may result in osteoclast activation and bone resorption. Potential haptens are originated from metal alloys or bone-cement. A meta-analysis has confirmed a higher probability of developing a metal hypersensitivity postoperatively and noted a greater risk of failed replacements compared to stable implants. Hypersensitivity to implants may present with a variety of symptoms such as pain, joint effusion, delayed wound/bone healing, persistent secretion, allergic dermatitis (localized or systemic), clicking noises, loss of joint function, instability and failure of the implant. Various diagnostic options have been offered, including patch testing, metal alloy patch testing, histology, lymphocyte transformation test (LTT), memory lymphocyte immunostimulation assay (MELISA), leukocyte migration inhibition test (LIF) and lymphocyte activation test (LAT). No significant differences between in vivo and in vitro methods have been found. Due to unconvincing evidence for screening methods, predictive tests are not recommended for routine performance. Infectious aetiology always needs to be excluded. As there is a lack of evidence on large-scale studies with regards to the optimal treatment option, management currently relies on individual case-by-case decisions. Several options for patients with (suspected) metal-related hypersensitivity exist and may include materials based on ceramic, titanium or oxinium or modified surfaces. Promising results have been reported, but long-term experience is lacking. More large-scaled studies are needed in this context. In patients with bone-cement hypersensitivity, the component suspected for hypersensitivity should be avoided. The development of
Preston, Charles F; Bhandari, Mohit; Fulkerson, Eric; Ginat, Danial; Koval, Kenneth J; Egol, Kenneth A
Original studies at orthopaedic meetings are presented on the podium and in poster format. Publication of those studies in peer-reviewed journals is the standard of communicating scientific data to colleagues. Investigators of previous studies have reported publication rates, but never differentiated between the modes of presentation. We evaluated the annual meeting of the Orthopaedic Trauma Association from 1994-1998 and found that studies presented on the podium were 1.3 times more likely to be published than those presented in a poster format (67% versus 52%). The mean time to publication was similar, 21.6 months for poster presentations and 24.8 months for podium presentations. Podium presentations were more likely to be published in the Journal of Orthopaedic Trauma, Clinical Orthopaedics and Related Research, and the Journal of Bone and Joint Surgery (American and British editions). Our findings suggest different rates and distribution of publication between podium and poster presentations at an international trauma meeting. These findings should be considered when evaluating studies of interest at the Orthopaedic Trauma Association meeting.
Johnson, Anthony E; Gerlinger, Tad L; Born, Christopher T
A disaster is a catastrophic event that disrupts normal infrastructure to such a degree that normal response mechanisms and capabilities cannot manage what is required to respond appropriately to the event. Launched after the largest urban disaster in modern history--the 2010 Haiti Earthquake--the American Academy of Orthopaedic Surgeons/Society of Military Orthopaedic Surgeons/Orthopaedic Trauma Association/Pediatric Orthopaedic Association of North America (AAOS/SOMOS/OTA/POSNA) Disaster Response Course (DRC) is designed to prepare orthopaedic surgeons for service in disaster response and humanitarian assistance efforts in both the acute phases as well as in the recovery and reconstructions phases. To date, 395 orthopaedic surgeons have completed the DRC and 286 (72.4%) have opted to become registered disaster responders.
Mitchell, Phillip M; Thakore, Rachel; Obremskey, Alexandra; Sethi, Manish K
Healthcare policy has changed drastically, and with the 50-year anniversary of the passage of Medicare approaching in 2015, the authors evaluate the development of the current healthcare system and its relationship to the development of modern orthopaedic trauma. With more changes in healthcare policy forthcoming, it is increasingly important for the orthopaedic traumatologist to understand how changes in policy will affect practice. Historically, the motivators for change have remained largely the same over the past 50 years. The development of diagnosis-related groups, the resource-based relative value scale, and the sustainable growth rate are 3 defining policies that were designed to control costs, but which had an unexpected effect on those caring for the trauma population. Healthcare reform has a unique effect on those systems where care is dictated by a defining event or injury. Evaluating the development of trauma systems, the authors find that legislation directed toward the trauma population has been driven by the study of patient outcomes, providing an opportunity for orthopaedic traumatologists to contribute to future changes in policy. As healthcare policy changes begin to take effect, having a thorough understanding of reform and its drivers will be increasingly important in taking an active role in advocating for the field of orthopaedic trauma and its patients.
Wegener, Stephen T; Carroll, Eben A; Gary, Joshua L; McKinley, Todd O; OʼToole, Robert V; Sietsema, Debra L; Castillo, Renan C; Frey, Katherine P; Scharfstein, Daniel O; Huang, Yanjie; Collins, Susan C J; MacKenzie, Ellen J
The impact of the Trauma Collaborative Care (TCC) program on surgeon confidence in managing the psychosocial sequelae of orthopaedic trauma was evaluated as part of a larger prospective, multisite, cluster clinical trial. We compared confidence and perceived resource availability among surgeons practicing in trauma centers that implemented the TCC program with orthopaedic trauma surgeons in similar trauma centers that did not implement the TCC. Prospective cohort design. Level-I trauma centers. Attending surgeons and fellows (N = 95 Pre and N = 82 Post). Self-report 10-item measure of surgeon confidence in managing psychosocial issues associated with trauma and perceived availability of support resources. Analyses, performed on the entire sample and repeated on the subset of 52 surgeons who responded to the survey at both times points, found surgeons at intervention sites experienced a significantly greater positive improvement (P < 0.05) in their (1) belief that they have strategies to help orthopaedic trauma patients change their psychosocial situation; (2) confidence in making appropriate referrals for orthopaedic trauma patients with psychosocial problems; and (3) belief that they have access to information to guide the management of psychosocial issues related to recovery. Initial data suggest that the establishment of the TCC program can improve surgeons' perceived availability of resources and their confidence in managing the psychosocial sequelae after injury. Further studies will be required to determine if this translates into beneficial patient effects. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Rivera, Jessica C; Greer, Renee M; Wenke, Joseph C; Ficke, James R; Johnson, Anthony E
The Military Orthopaedic Trauma Registry (MOTR) orginally began as part of the Department of Defense Trauma Registry (DoDTR) and became a live registry in 2013. As a quality improvement process, this study examined MOTR data for 20 female amputees compared with DoDTR data. The DoDTR provided diagnosis and procedure codes as a list but no details. The MOTR provided additional data, including specific limb, fracture classifications, and associated injuries per limb. The MOTR allowed for construction of a treatment time line for each limb, including number and timing of debridements, antibiotics, and implant types. Orthopaedic-specific complications were also coded more frequently in the MOTR and clearly identified with a specific injury and treatment. During initial quality control checks, the MOTR provides a greater volume and granularity of detail for orthopaedic-specific injury and treatment information, indicating that the MOTR is on track to provide a valuable repository for data-driven orthopaedic management of combat injury.
Lawrence, John E; Khanduja, Vikas
To compare the trauma experience gained by a trainee at a United Kingdom major trauma centre and a secondary level hospital in South Africa. A profile of inpatient trauma cases during a five-week period in Addenbrooke's Hospital, Cambridge and Somerset Hospital, Cape Town was created. This was achieved by recording various parameters for each patient admitted including age, gender, injury, mechanism of injury and postal/area code. This, together with details of the departments themselves, allows a comparison of the amount and variety of orthopaedic trauma cases experienced by an individual trainee in each setting. The trauma profiles differed significantly. Patients in Cape Town were younger and more likely to be male. In the young, injury in Cape Town was more likely to occur due to assault or being struck by a vehicle, whilst patients in Cambridge were more likely to be injured whilst in a vehicle or in high energy falls. In older patients, trauma at both centres was almost exclusively due to mechanical falls. In a given age group, injuries at the two centres were similar, however the majority of patients admitted to Addenbrooke's were elderly, resulting in less variation in the overall injury profile. The trauma profile of a major trauma centre in the United Kingdom is less varied than that of a South African secondary centre, with significantly fewer cases per surgeon. This suggests a more varied training experience in the developing world with a greater caseload.
Noordin, Shahryar; Masri, Bassam A
To compare the pattern of adult inpatient orthopaedic injuries admitted at three Vancouver hospitals following one of the worst winter snowstorms in the region with the preceding control winter period. The surveillance study was conducted at the University of British Columbia, Vancouver, Canada, 2007 to 2010. Inpatient adult admissions for orthopaedic injuries at three hospitals were recorded, including age, gender, anatomic location of injury, type of fracture (open or closed), fixation method (internal versus external fixation), and length of acute care hospital stay. Comparisons between admissions during this weather pattern and admission during a previous winter with minimal snow were made. SPSS 19 was used for statistical analysis. Of the 511 patients admitted under Orthopaedic trauma service during the significant winter snowstorms of December 2008-January 2009, 100 (19.6%) (Cl: 16.2%-23.2%) were due to ice and snow, whereas in the preceding mild winter only 18 of 415 (4.3%) (CI: 2.5%-6.8%) cases were related to snow (p < 0.05). Ankle and wrist fractures were the most frequent injuries during the index snow storm period (p < 0.05). At all the three institutions, 97 (96.5%) fractures were closed during the snowstorm as opposed to 17 (95%) during the control winter period. Internal fixation in 06 (89%) fractures as opposed to external fixation in 12 (11%) patients was the predominant mode of fixation across the board during both time periods. The study demonstrated a significantly higher inpatient orthopaedic trauma volume during the snowstorm. More rigorous prospective studies need to be designed to gain further insight to solving these problems from a public health perspective.
Karthik, K; Colegate-Stone, T; Dasgupta, P; Tavakkolizadeh, A; Sinha, J
The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics. ©2015 The British Editorial Society of Bone & Joint Surgery.
Polyzois, Ioannis; Tsitskaris, Konstantinos; Oussedik, Sam
The incidence of pudendal nerve palsy following routine trauma and elective orthopaedic surgery procedures ranges from 1.9% to 27.6%. Excessive and/or prolonged traction against the perineal post of a traction table, leading to direct compression and localised ischaemia to the nerve are suggested mechanisms of injury. Misuse of traction and the inappropriate placement of the perineal post, leading to crushing and stretching of the pudendal nerve, are two main contributing factors leading to its postoperative palsy. The sequelae may be sensory, motor or mixed. In most cases, these injuries are transient and tend to resolve within several weeks or months. However, complete neurological recovery may be unpredictable and the effects of ongoing dysfunction potentially disastrous for the individual. In terms of preventative measures, magnitude and duration of traction time should be minimised; traction should be limited to the critical operative steps only. Additionally, the perineal post should be placed between the genitalia and the contralateral leg. A well-padded, large-diameter perineal post should be used (>10cm). Adequate muscle relaxation during anaesthesia is particularly important in young men who have strong muscles and thus require larger traction forces when compared to elderly patients. Orthopaedic surgeons should be aware of the pathophysiology behind the development of this palsy and the measures that can be employed to reduce its occurrence. In procedures where a traction table is employed, consenting for pudendal nerve palsy should be considered by the surgical team.
Paul, Ashish; John, Bobby; Pawar, Basant; Sadiq, Shalinder
This prospective study was undertaken to determine the incidence of acute renal failure (ARF) and to identify factors contributing to development of ARF in orthopaedic trauma patients. A total of 55 patients who presented over a period of one year with trauma to upper and lower limbs were studied. Patients with renal injury, chest or abdominal injury, isolated fractures of the hands, feet and axial skeleton involvement were excluded. Out of these, five developed acute renal failure, three recovered and two died. The overall incidence of ARF in this study was 9.1%. Patients with lower limb injuries are at higher risk of developing ARF. Mangled Extremity Severity Score (MESS) > or = 7, higher age, patient presenting with shock, increased myoglobin levels in urine and serum have been correlated with a greater risk of patients developing ARF and a higher mortality. This study attempts to determine the magnitude of crush injury causing renal failure and the incidence of renal failure in patients with injuries affecting the appendicular skeleton exclusively.
Whiting, Paul S.; White-Dzuro, Gabrielle A.; Greenberg, Sarah E.; VanHouten, Jacob P.; Avilucea, Frank R.; Obremskey, William T.; Sethi, Manish K.
Background: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are recognized as major causes of morbidity and mortality in orthopaedic trauma patients. Despite the high incidence of these complications following orthopaedic trauma, there is a paucity of literature investigating the clinical risk factors for DVT in this specific population. As our healthcare system increasingly emphasizes quality measures, it is critical for orthopaedic surgeons to understand the clinical factors that increase the risk of DVT following orthopaedic trauma. Objectives: Utilizing the ACS-NSQIP database, we sought to determine the incidence and identify independent risk factors for DVT following orthopaedic trauma. Patients and Methods: Using current procedural terminology (CPT) codes for orthopaedic trauma procedures, we identified a prospective cohort of patients from the 2006 to 2013 ACS-NSQIP database. Using Wilcoxon-Mann-Whitney and chi-square tests where appropriate, patient demographics, comorbidities, and operative factors were compared between patients who developed a DVT within 30 days of surgery and those who did not. A multivariate logistic regression analysis was conducted to calculate odds ratios (ORs) and identify independent risk factors for DVT. Significance was set at P < 0.05. Results: 56,299 orthopaedic trauma patients were included in the analysis, of which 473 (0.84%) developed a DVT within 30 days. In univariate analysis, twenty-five variables were significantly associated with the development of a DVT, including age (P < 0.0001), BMI (P = 0.037), diabetes (P = 0.01), ASA score (P < 0.0001) and anatomic region injured (P < 0.0001). Multivariate analysis identified several independent risk factors for development of a DVT including use of a ventilator (OR = 43.67, P = 0.039), ascites (OR = 41.61, P = 0.0038), steroid use (OR = 4.00, P < 0.001), and alcohol use (OR = 2.98, P = 0.0370). Compared to patients with upper extremity trauma, those with lower
New, Steve; Hadi, Mohammed; Pickering, Sharon; Robertson, Eleanor; Morgan, Lauren; Griffin, Damian; Collins, Gary; Rivero-Arias, Oliver; Catchpole, Ken; McCulloch, Peter
Objectives To examine the effectiveness of a “systems” approach using Lean methodology to improve surgical care, as part of a programme of studies investigating possible synergy between improvement approaches. Setting A controlled before-after study using the orthopaedic trauma theatre of a UK Trust hospital as the active site and an elective orthopaedic theatre in the same Trust as control. Participants All staff involved in surgical procedures in both theatres. Interventions A one-day “lean” training course delivered by an experienced specialist team was followed by support and assistance in developing a 6 month improvement project. Clinical staff selected the subjects for improvement and designed the improvements. Outcome Measures We compared technical and non-technical team performance in theatre using WHO checklist compliance evaluation, “glitch count” and Oxford NOTECHS II in a sample of directly observed operations, and patient outcome (length of stay, complications and readmissions) for all patients. We collected observational data for 3 months and clinical data for 6 months before and after the intervention period. We compared changes in measures using 2-way analysis of variance. Results We studied 576 cases before and 465 after intervention, observing the operation in 38 and 41 cases respectively. We found no significant changes in team performance or patient outcome measures. The intervention theatre staff focused their efforts on improving first patient arrival time, which improved by 20 minutes after intervention. Conclusions This version of “lean” system improvement did not improve measured safety processes or outcomes. The study highlighted an important tension between promoting staff ownership and providing direction, which needs to be managed in “lean” projects. Space and time for staff to conduct improvement activities are important for success. PMID:27124012
New, Steve; Hadi, Mohammed; Pickering, Sharon; Robertson, Eleanor; Morgan, Lauren; Griffin, Damian; Collins, Gary; Rivero-Arias, Oliver; Catchpole, Ken; McCulloch, Peter
To examine the effectiveness of a "systems" approach using Lean methodology to improve surgical care, as part of a programme of studies investigating possible synergy between improvement approaches. A controlled before-after study using the orthopaedic trauma theatre of a UK Trust hospital as the active site and an elective orthopaedic theatre in the same Trust as control. All staff involved in surgical procedures in both theatres. A one-day "lean" training course delivered by an experienced specialist team was followed by support and assistance in developing a 6 month improvement project. Clinical staff selected the subjects for improvement and designed the improvements. We compared technical and non-technical team performance in theatre using WHO checklist compliance evaluation, "glitch count" and Oxford NOTECHS II in a sample of directly observed operations, and patient outcome (length of stay, complications and readmissions) for all patients. We collected observational data for 3 months and clinical data for 6 months before and after the intervention period. We compared changes in measures using 2-way analysis of variance. We studied 576 cases before and 465 after intervention, observing the operation in 38 and 41 cases respectively. We found no significant changes in team performance or patient outcome measures. The intervention theatre staff focused their efforts on improving first patient arrival time, which improved by 20 minutes after intervention. This version of "lean" system improvement did not improve measured safety processes or outcomes. The study highlighted an important tension between promoting staff ownership and providing direction, which needs to be managed in "lean" projects. Space and time for staff to conduct improvement activities are important for success.
Stewart, Barclay T; Gyedu, Adam; Tansley, Gavin; Yeboah, Dominic; Amponsah-Manu, Forster; Mock, Charles; Labi-Addo, Wilfred; Quansah, Robert
Orthopaedic conditions incur more than 52 million disability-adjusted life years annually worldwide. This burden disproportionately affects low and middle-income countries, which are least equipped to provide orthopaedic care. We aimed to assess orthopaedic capacity in Ghana, describe spatial access to orthopaedic care, and identify hospitals that would most improve access to care if their capacity was improved. Seventeen perioperative and orthopaedic trauma care-related items were selected from the World Health Organization's Guidelines for Essential Trauma Care. Direct inspection and structured interviews with hospital staff were used to assess resource availability and factors contributing to deficiencies at 40 purposively sampled facilities. Cost-distance analyses described population-level spatial access to orthopaedic trauma care. Facilities for targeted capability improvement were identified through location-allocation modeling. Orthopaedic trauma care assessment demonstrated marked deficiencies. Some deficient resources were low cost (e.g., spinal immobilization, closed reduction capabilities, and prosthetics for amputees). Resource nonavailability resulted from several contributing factors (e.g., absence of equipment, technology breakage, lack of training). Implants were commonly prohibitively expensive. Building basic orthopaedic care capacity at 15 hospitals without such capacity would improve spatial access to basic care from 74.9% to 83.0% of the population (uncertainty interval [UI] of 81.2% to 83.6%), providing access for an additional 2,169,714 Ghanaians. The availability of several low-cost resources could be better supplied by improvements in organization and training for orthopaedic trauma care. There is a critical need to advocate and provide funding for orthopaedic resources. These initiatives might be particularly effective if aimed at hospitals that could provide care to a large proportion of the population.
Cosic, Filip; Kimmel, Lara; Edwards, Elton
the quality loop. The present study has highlighted that the standard of orthopaedic trauma medical record keeping at an Australian Level 1 trauma centre is below what is expected and several key areas of documentation require improvement. This paper further evaluates the system performance of the out-patient system, an area where, to the authors knowledge, there is no previous work published. The findings show that the performance was below what is expected for surgical review, with many patients failing to be reviewed by their operating surgeon.What are the implications for practitioners? The present study shows that there is a poor level of documentation and a standard of out-patient review below what is expected. The implications of these findings will be to highlight current deficiencies to practitioners and promote change in current practice to improve the quality of medical record documentation among medical staff. Further, the findings of poor system performance will promote change in the current system of delivering out-patient care to patients.
Willett, K M; Gray, B; Moran, C G; Giannoudis, P V; Pallister, I
Clinical practice should be informed by high quality evidence, of which randomised controlled trials (RCTs) are considered the gold standard. Surgical trials are inherently difficult with potential problems around clinical equipoise and participant acceptability. This is often most true with trial designs comparing operative and non-operative treatments. It is hoped that research activity can be maximised by collaborating in (a) the identification of research questions and (b) involvement in clinical trials. Development of the national research networks can be utilised to provide support for research endeavours within the orthopaedic trauma community. To identify and prioritise the research questions felt to be of most importance by the orthopaedic trauma community. Research studies will be considered for questions given the highest priority. A Delphi approach was used to determine consensus between the faculty members of the AOUK. A two round process was used to elicit the research questions and then to rank them in order of priority. 217 members of the AOUK Long Bone Faculty were asked to submit research questions, predominantly consultant orthopaedic surgeons. A 22% response rate generated 147 questions. These were collated and the most frequent 24 sent back out for ranking by mean scores. A 55% response to this second round identified 10 top questions. Literature searches for these 10 looked at current knowledge of the subject, completed and ongoing research projects. We also looked at the advantages and disadvantages of undertaking a study and the most appropriate methodology. The response rates demonstrated a clear interest in developing a collaborative research strategy. This can be enhanced by utilising the support of the National Institute of Health Research Clinical Research Networks (NIHR CRN). 2010 Elsevier Ltd. All rights reserved.
Sielatycki, John A; Sawyer, Jeffrey R; Mir, Hassan R
To investigate recent trends in the orthopaedic trauma workforce and to assess whether supply of orthopaedic trauma surgeons (OTS) matches the demand for their skills. Supply estimated using Orthopaedic Trauma Association (OTA) membership and American Academy of Orthopaedic Surgeons census data. The annual number of operative pelvic and acetabular fractures reported by American College of Surgeons verified trauma centers in the National Trauma Data Bank (NTDB) was used as a surrogate of demand. Because surrogates were used, the annual rate of change in OTA membership versus rate of change in operative injuries per NTDB center was compared. From 2002 to 2012, reported operative pelvic and acetabular injuries increased by an average of 21.0% per year. The number of reporting trauma centers increased by 27.2% per year. The number of OTA members increased each year except in 2009, with mean annual increase of 9.8%. The mean number of orthopaedic surgeons per NTDB center increased from 7.98 to 8.58, an average of 1.5% per year. The annual number of operative pelvic and acetabular fractures per NTDB center decreased from 27.1 in 2002 to 19.03 in 2012, down 2.0% per year. In the United States, from 2002 to 2012, the number of OTS trended upward, whereas operative pelvic and acetabular cases per reporting NTDB center declined. These trends suggest a net loss of such cases per OTS over this period.
Wasko, Marcin K.; Kaminski, Rafal
Since the first description in 2002 by Paley and Herzenberg, antibiotic bone cement nails (ACNs) have become an effective tool in the orthopaedic trauma surgeons' hands. They simultaneously elute high amounts of antibiotics into medullary canal dead space and provide limited stability to the debrided long bone. In this paper, we perform a systematic review of current evidence on ACNs in orthopaedic trauma and provide an up-to-date review of the indications, operative technique, failure mechanisms, complications, outcomes, and outlooks for the ACNs use in long bone infection. PMID:26509153
Hill, Austin; Althausen, Peter L; O'Mara, Timothy J; Bray, Timothy J
The financial realities of providing trauma care to injured patients can make it difficult to produce an accurate assessment of the cumulative value orthopaedic trauma surgeons provide to healthcare and university institutions. As with many political battles in the field of medicine, physicians who have been diligently focused on providing patient care were completely unaware of the impending upheaval around them. Whether orthopaedic trauma surgeons are employed or in some type of partnership with hospitals, too often surgeons find the relationship one-sided. In order to effectively negotiate with hospitals, surgeons must demonstrate the comprehensive value they provide to their respective healthcare institutions and universities. Orthopaedic trauma surgeons make direct and indirect financial contributions to the hospital in addition to educational and community services. The sum total of these valued contributions helps fund non-revenue generating programs, provides marketing opportunities, and improves the regional and national reputation of the healthcare institution. This paper provides a comprehensive review of the value contributed to healthcare institutions by orthopaedic trauma surgeons and will serve as a blueprint for all surgeons to accurately account for and demonstrate their value to hospitals while providing efficient and compassionate care to our patients.
Richter, Peter H; Yarboro, Seth; Kraus, Michael; Gebhard, Florian
Hybrid operating rooms have been used successfully in several surgical specialties, but no data have been published for orthopaedic trauma. We present our one-year orthopaedic trauma experience using a hybrid operating room, which incorporates 3D fluoroscopic imaging as well as navigation capabilities. Data were compiled for a series of 92 cases performed in an advanced hybrid operating room at the level one trauma center in Ulm, Germany. All patients who had surgery performed using this operating room during the first year were included. Setup time and surgical complications using hybrid operating room were recorded and analysed. The hybrid operating room resulted in no higher rate of complication than expected from the same cases in a conventional operating room. The hybrid room did however allow the surgeon to confidently place implants for orthopaedic trauma cases, and was most advantageous for spine and pelvis cases, both minimally invasive and conventional. Further, appropriate reduction and implant position was confirmed with 3D imaging prior to leaving the operating room and obviated the need for postoperative CT scan. Based on our one-year experience, the hybrid operating room is a useful and safe tool for orthopaedic trauma surgery.
Althausen, Peter L; Kauk, Justin R; Shannon, Steven; Lu, Minggen; O'Mara, Timothy J; Bray, Timothy J
Fellowship-trained orthopaedic traumatologists are presumably taught skill sets leading to "best practice" outcomes and more efficient use of hospital resources. This should result in more favorable economic opportunities when compared with general orthopaedic surgeons (GOSs) providing similar clinical services. The purpose of our study was to compare the operating room utilization and financial data of traumatologists versus GOSs at a level II trauma center. Retrospective review. Level II community-based trauma hospital. Patients who presented to the emergency room at our institution with fractures and orthopaedic conditions requiring surgical intervention from January 1, 2010, to December 31, 2011. Operative fracture fixation by members of our orthopaedic trauma panel, including fellowship and nontrauma fellowship-trained orthopaedic surgeons. Our institutional database was queried to determine operative times, surgical supply and implant costs, and surgery labor expenses. Patients were stratified according to those treated by our trauma panel's 3 traumatologists and those treated by the 15 GOSs on our trauma panel. These 2 groups were then compared using standard statistical methods. A total of 6449 orthopedic cases were identified and 2076 of these involved fracture care. One thousand one hundred ninety-nine patients were treated by traumatologists and 877 by GOSs. There was no statistical difference detected in American Society of Anesthesiologists score between trauma and nontrauma groups. Overall, the traumatologist group demonstrated significantly decreased procedure times when compared with the GOS group (55.6 vs. 75.8 minutes, P , 0.0001). In 16 of 18 most common procedure types, traumatologists were more efficient. This led to significantly decreased surgical labor costs ($381.4 vs. $484.8; P < 0.0001) and surgical supply and implant costs ($2567 vs. $3003; P < 0.0001). This study demonstrates that in our communitybased trauma system, fracture care
Ihejirika, Rivka C; Thakore, Rachel V; Sathiyakumar, Vasanth; Ehrenfeld, Jesse M; Obremskey, William T; Sethi, Manish K
Although recent literature has demonstrated the utility of the ASA score in predicting postoperative length of stay, complication risk and potential utilization of other hospital resources, the ASA score has been inconsistently assigned by anaesthesia providers. This study tested the reliability of assignment of the ASA score classification by both attending anaesthesiologists and anaesthesia residents specifically among the orthopaedic trauma patient population. Nine case-based scenarios were created involving preoperative patients with isolated operative orthopaedic trauma injuries. The cases were created and assigned a reference score by both an attending anaesthesiologist and orthopaedic trauma surgeon. Attending and resident anaesthesiologists were asked to assign an ASA score for each case. Rater versus reference and inter-rater agreement amongst respondents was then analyzed utilizing Fleiss's Kappa and weighted and unweighted Cohen's Kappa. Thirty three individuals provided ASA scores for each of the scenarios. The average rater versus reference reliability was substantial (Kw=0.78, SD=0.131, 95% CI=0.73-0.83). The average rater versus reference Kuw was also substantial (Kuw=0.64, SD=0.21, 95% CI=0.56-0.71). The inter-rater reliability as evaluated by Fleiss's Kappa was moderate (K=0.51, p<.001). An inter-rater comparison within the group of attendings (K=0.50, p<.001) and within the group of residents were both moderate (K=0.55, p<.001). There was a significant increase in the level of inter-rater reliability from the self-reported 'very uncomfortable' participants to the 'very comfortable' participants (uncomfortable K=0.43, comfortable K=0.59, p<.001). This study shows substantial agreement strength for reliability of the ASA score among anaesthesiologists when evaluating orthopaedic trauma patients. The significant increase in inter-rater reliability based on anaesthesiologists' comfort with the ASA scoring method implies a need for further evaluation
Ghani, Yaser; Thakrar, Raj R; Palmer, Jon; Konan, Sujith; Donaldson, James; Olivier, Andre; Gikas, Panos; Briggs, Tim
Undergraduate education in musculoskeletal health is currently insufficient in most medical schools worldwide, in both basic sciences and clinical training. A national survey was carried out to obtain views of current doctors from various specialties about undergraduate and foundation training in trauma and orthopaedics.
Obremskey, William; Molina, Cesar; Collinge, Cory; Nana, Arvind; Tornetta, Paul; Sagi, Claude; Schmidt, Andrew; Probe, Robert; Ahn, Jaimo; Browner, Bruce D
Open fractures are one of the injuries with the highest rate of infection that orthopaedic trauma surgeons treat. The main purpose of this survey was to determine current practice and practice variation among Orthopaedic Trauma Association (OTA) members and make treatment recommendations based on previously published resources. Survey. Web-based survey. Three hundred seventy-nine orthopaedic trauma surgeons. A 15-item questionnaire-based study titled "OTA Open Fracture Survey" was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze numerous aspects of open fracture management, focusing on parameters of initial and definitive treatment. Eighty-six percent of participants responded that a period of time of less than 1 hour is the optimal time to antibiotic administration after identification of open fracture. Despite concerns with nephrotoxicity, 24.0%-76.3% of respondents reported the use of aminoglycosides in management of open fractures. A little over half of survey respondents continue antibiotics until next debridement in wounds that were not definitively closed after initial debridement and stabilization. Rapid administration of antibiotics in open fracture management is important. Aminoglycoside use is still prevalent despite evidence questioning efficacy and toxicity concerns. Time to debridement of open fractures is controversial among OTA members. Antibiotic administration is commonly continued >48 hours despite concerns raised by Surgical Infection Society and The Eastern Association of the Surgery of Trauma. Regarding study logistics, survey participation reminders should be used when conducting this type of study as it can increase data accrual by 50%. Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
Stirling, Euan R B; Lewis, Thomas L; Ferran, Nicholas A
Changing patterns of health care delivery and the rapid evolution of orthopaedic surgical techniques have made it increasingly difficult for trainees to develop expertise in their craft. Working hour restrictions and a drive towards senior led care demands that proficiency be gained in a shorter period of time whilst requiring a greater skill set than that in the past. The resulting conflict between service provision and training has necessitated the development of alternative methods in order to compensate for the reduction in 'hands-on' experience. Simulation training provides the opportunity to develop surgical skills in a controlled environment whilst minimising risks to patient safety, operating theatre usage and financial expenditure. Many options for simulation exist within orthopaedics from cadaveric or prosthetic models, to arthroscopic simulators, to advanced virtual reality and three-dimensional software tools. There are limitations to this form of training, but it has significant potential for trainees to achieve competence in procedures prior to real-life practice. The evidence for its direct transferability to operating theatre performance is limited but there are clear benefits such as increasing trainee confidence and familiarity with equipment. With progressively improving methods of simulation available, it is likely to become more important in the ongoing and future training and assessment of orthopaedic surgeons.
Davids, Jon R; Weigl, Daniel M; Edmonds, Joye P; Blackhurst, Dawn W
Reference accuracy of articles published in the biomedical literature is determined by the presence of citation and quotation errors. A recent review demonstrated that the median citation error rate per biomedical journal was 39%, and the median quotation error rate per journal was 20%. Reference accuracy in pediatric orthopaedic articles has not been previously reported, to our knowledge. Two hundred references from twenty articles published in four peer-reviewed orthopaedic journals were randomly selected for assessment of citation and quotation accuracy. Full-text copies of all original references were obtained by interlibrary loan methods and reviewed directly to establish citation accuracy. The presence of citation errors was determined by a single investigator. The relevance of citation errors was determined by assessing the ease of reference retrieval through PubMed. Quotation accuracy was determined by two examiners who reviewed each of the twenty articles and 200 references to compare the claims made for the references in the article against the data and opinions expressed in the actual reference. The total citation error rate across all of the journals was 26% (fifty-one of 200 references) with a 95% confidence interval of 16.5% to 37.3%. The median citation error rate per journal was 27% (range, 10% to 38%). Although citation errors were common, most were of minimal significance, as 196 of the 200 references could be retrieved with ease from PubMed. The total quotation error rate across all of the articles was 38% (152 of 398 reference citations) with a 95% confidence interval of 30.1% to 47.0%. The median quotation error rate per journal was 38% (range, 28% to 46%). Citation and quotation errors are common in the pediatric orthopaedic literature. Reference accuracy continues to be a substantial problem in the biomedical literature despite recent technological advances such as online databases, easily accessible search engines, and widely available
Orthopaedic limb reconstruction patients often have wounds that are difficult to heal either due to the underlying problems, their surgery, underlying comorbidities or a combination of these factors. Negative pressure wound therapy (NPWT) is a useful tool with which to manage these wounds; however, many systems are not ideal for use in the patient's home, due in part to size and complexity. There are also staff training issues if transferring patients to an area which does not routinely use negative pressure systems. This paper reports the outcomes for some of the patients who were treated with a novel, single-use NPWT device in a orthopaedic trauma/limb reconstruction unit.
Obremskey, William; Molina, Cesar; Collinge, Cory; Tornetta, Paul; Sagi, Claude; Schmidt, Andrew; Probe, Robert; Ahn, Jaimo; Nana, Arvind
Treatment of segmental long bone defects is one of the areas of substantial controversy in current orthopaedic trauma. The main purpose of this survey was to determine current practice and practice variation within the Orthopaedic Trauma Association (OTA) membership on this topic. Survey. Web-based survey. Three hundred seventy-nine orthopaedic trauma surgeons. A 15-item questionnaire-based study titled "OTA Open Fracture Survey" was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze various aspects of open fracture management, focusing on definitive treatment and materials used for grafting in "critical-sized" segmental bone defects. Between July and August 2012, a total of 379/1545 members responded for a 25% response rate. Overall, 89.5% (339/379) of respondents use some sort of antibiotic cement spacer before bone grafting. It was found that 92% of respondents preferred to use some type of autograft at time of definitive grafting of segmental defects. When using a grafting technique, 88% said they used some type of antibiotic cement. Within that context, 60.1% said graft placement should be done at 6 weeks. There continues to be substantial variation in the timing of bone graft placement after soft tissue healing and the source and form of graft used. The use of antibiotic cement is common in segmental defects that require delayed bone grafting. Obtaining base-line practice characteristics on controversial topics will help provide a foundation for assessing research needs and, therefore, goals. Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
Castillo, Renan C; Raja, Srinivasa N; Frey, Katherine P; Vallier, Heather A; Tornetta, Paul; Jaeblon, Todd; Goff, Brandon J; Gottschalk, Allan; Scharfstein, Daniel O; OʼToole, Robert V
Poor pain control after orthopaedic trauma is a predictor of physical disability and numerous negative long-term outcomes. Despite increased awareness of the negative consequences of poorly controlled pain, analgesic therapy among hospitalized patients after orthopaedic trauma remains inconsistent and often inadequate. The Pain study is a 3 armed, prospective, double-blind, multicenter randomized trial designed to evaluate the effect of standard pain management versus standard pain management plus perioperative nonsteroidal anti-inflammatory drugs or pregabalin in patients of ages 18-85 with extremity fractures. The primary outcomes are chronic pain, opioid utilization during the 48 hours after definitive fixation and surgery for nonunion in the year after fixation. Secondary outcomes include preoperative and postoperative pain intensity, adverse events and complications, physical function, depression, and post-traumatic stress disorder. One year treatment costs are also compared between the groups.
Fayaz, Hangama C; Haas, Norbert; Kellam, James; Bavonratanavech, Suthorn; Parvizi, Javad; Dyer, George; Pohlemann, Tim; Jerosch, Jörg; Prommersberger, Karl-Josef; Pape, Hans Christoph; Smith, Malcolm; Vrahas, Marc; Perka, Carsten; Siebenrock, Klaus; Elhassan, Bassem; Moran, Christopher; Jupiter, Jesse B
The international orthopaedic community aims to achieve the best possible outcome for patient care by constantly modifying surgical techniques and expanding the surgeon's knowledge. These efforts require proper reflection within a setting that necessitates a higher quality standard for global orthopaedic publication. Furthermore, these techniques demand that surgeons acquire information at a rapid rate while enforcing higher standards in research performance. An international consensus exists on how to perform research and what rules should be considered when publishing a scientific paper. Despite this global agreement, in today's "Cross Check Era", too many authors do not give attention to the current standards of systematic research. Thus, the purpose of this paper is to describe these performance standards, the available choices for orthopaedic surgeons and the current learning curve for seasoned teams of researchers and orthopaedic surgeons with more than three decades of experience. These lead to provide an accessible overview of all important aspects of the topics that will significantly influence the research development as we arrive at an important globalisation era in orthopaedics and trauma-related research.
Gage, Mark J; Yoon, Richard S; Gaines, Robert J; Dunbar, Robert P; Egol, Kenneth A; Liporace, Frank A
Dead space is defined as the residual tissue void after tissue loss. This may occur due to tissue necrosis after high-energy trauma, infection, or surgical debridement of nonviable tissue. This review provides an update on the state of the art and recent advances in the management of osseous and soft tissue defects. Specifically, our focus will be on the initial dead space assessment, provisional management of osseous and soft tissue defects, techniques for definitive reconstruction, and dead space management in the setting of infection. Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
Kasch, R; Wirkner, J; Meder, A; Abert, E; Abert, M; Schulz, A P; Walcher, F; Gümbel, D; Obertacke, U; Schwanitz, P; Merk, H; Froehlich, S
The general shortage of medical doctors in Germany can also be felt in the area of trauma and orthopaedics. Medical elective placements, in Germany known as "Famulatur", are sensitive interfaces between the theoretical university studies and the practical medical workplace. In this research project, the aim was to study how medical students perceive these types of placements and if it alters their decision making when planning their further career. During the summer term of 2012, 9079 medical students answered an online questionnaire. Of these, the subgroup was evaluated that had had a placement of at least 4 weeks in the field of trauma and orthopaedics. Overall, 37 test items about this placement and further career steps were included in this study. Groups were evaluated separately by the item "I am considering a career in trauma and orthopaedics" (PJ-Ja) versus "I am not considering a career in trauma and orthopaedics" (PJ-Nein). Overall 397 students were included in this study; 55 % were female. 267 (67.3 %) stated: "I am considering a career in trauma and orthopaedics"; 130 (32.7 %) were not. There was no significant difference in age or sex between these groups (sex: χ²= 2.50, p = 0.114; age: F[1.93]< 1, p = 0.764). Specific and statistically significant differences between those groups were found in the items team integration, ward climate, qualification of teaching, training for specific knowledge in the field, practical aspects of the tasks performed, general planning and structure of the elective achievement of the teaching goals. Knowledge of satisfaction during medical elective placements is essential if one aims to inspire students for a specific medical profession. Instructors who can identify weaknesses and deficits in their training regime can therefore in the future increase the number of medical doctors who choose their speciality. The foundation of personal development has to be laid very early in the career of medical students
Sexton, S A; Ferguson, N; Pearce, C; Ricketts, D M
Many studies published in medical journals do not consider the statistical power required to detect a meaningful difference between study groups. As a result, these studies are often underpowered: the sample size may not be large enough to pick up a statistically significant difference (or other effect of interest) of a given size between the study groups. Therefore, the conclusion that there is no statistically significant difference between groups cannot be made unless a study has been shown to have sufficient power. The aim of this study was to establish the prevalence of negative studies with inadequate statistical power in British journals to which orthopaedic surgeons regularly submit. We assessed all papers in the last consecutive six issues prior to the start of the study (April 2005) in The Journal of Bone and Joint Surgery (British), Injury, and Annals of the Royal College of Surgeons of England. We sought published evidence that a power analysis had been performed in association with the main hypothesis of the paper. There were a total of 170 papers in which a statistical comparison of two or more groups was undertaken. Of these 170 papers, 49 (28.8%) stated as their primary conclusion that there was no statistically significant difference between the groups studied. Of these 49 papers, only 3 (6.1%) had performed a power analysis demonstrating adequate sample size. These results demonstrate that the majority of negative studies in the British orthopaedic literature that we have looked at have not performed the statistical analysis necessary to reach their stated conclusions. In order to remedy this, we recommend that the journals sampled include the following guidance in their instructions to authors: the statement 'no statistically significant difference was found between study groups' should be accompanied by the results of a power analysis.
Lee, Adam K; Dodd, Ashley C; Lakomkin, Nikita; Yarlagadda, Mahesh; Jahangir, A Alex; Collinge, Cory A; Sethi, Manish K
Postoperative cardiac events in orthopaedic trauma patients constitute severe morbidity and mortality. It is therefore increasingly important to determine patient risk factors that are predictive of postoperative myocardial infarctions and cardiac arrests. This study sought to assess if there is an association between anatomic area and cardiac complications in the orthopaedic trauma patient. From 2006-2013, a total of 361,402 orthopaedic patients were identified in the NSQIP database using Current Procedural Terminology (CPT) codes. Of these, 56,336 (15.6%) patients were identified as orthopaedic trauma patients broken down by anatomic region: 11,905 (21.1%) upper extremity patients (UE), 29,009 (51.5%) hip/pelvis patients (HP), and 15,422 (27.4%) lower extremity patients (LE) using CPT codes. Patients were defined as having adverse cardiac events if they developed myocardial infarctions or cardiac arrests within 30days after surgery. Chi-squared analysis was used to determine if there was an association between anatomic area and rates of cardiac events. Multivariate logistical analysis was used with over 40 patient characteristics including age, gender, history of cardiac disease, and anatomic region as independent predictors to determine whether anatomic area significantly predicted the development of cardiac complications. There were significant differences in baseline demographics among the three groups: HP patients had the greatest average age (77.6 years) compared to 54.8 years for UE patients and 54.1 years in LE patients (p<0.001). HP patients also had the highest average ASA score (3.0) (p<0.001). There was a significant difference in adverse cardiac events based on anatomic area: 0.27% (32/11,905) UE patients developed cardiac complications compared to 2.15% (623/29,009) HP patients and 0.61% (94/15,422) LE patients. After multivariate analysis, HP patients were significantly more likely to develop cardiac complications compared to both UE patients (OR: 6
Knutsen, Elisa J; Paryavi, Ebrahim; Castillo, Renan C; OʼToole, Robert V
Among orthopaedic trauma patients, little is known regarding the relationship between patient satisfaction and patient levels of depression and "activation" (level of involvement of patient in his or her own care). Our hypothesis was that satisfaction is correlated to levels of depression and activation. Patient questionnaires. Level 1 trauma center. One hundred twenty-four patients with at least one fracture. Patients were evaluated at orthopaedic trauma clinics 6 weeks or longer after injury. Patient Satisfaction Questionnaire (PSQ), Patient Activation Measure, and Patient Health Questionnaire, a screening and evaluation tool for the presence and severity of depression. Spearman correlation coefficients assessed the relationship between activation level and depression severity with PSQ domains. Bivariate and multivariate linear regression models determined independent effects of depression and activation on general satisfaction. Patient satisfaction was moderate to high in general (mean score, 4.17). Spearman correlation coefficients were high for patient activation and all PSQ domains (generally >0.3, P < 0.05). Correlation coefficients were weaker for depression and PSQ domains (rho range, 0.16-0.33). Final multivariate linear regression model indicated improvement in general satisfaction of 0.14 with increasing patient activation. A decrease in general satisfaction of -0.03 was noted with increasing Patient Health Questionnaire depression score. Patient satisfaction is strongly correlated with patient activation but less correlated with the presence of depression. Patient satisfaction after orthopaedic trauma might be improved by encouraging and coaching patients on how to be more involved in their own health care. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Toussaint, Rull James; Bergeron, Stephane G; Weaver, Michael J; Tornetta, Paul; Vrahas, Mark S; Harris, Mitchel B
The 2006 Massachusetts Healthcare Reform (MHR) has resulted in health coverage for 98.1% of residents in Massachusetts. The purpose of this study was to evaluate the effect of MHR on the actual rate of uninsured individuals in the orthopaedic trauma population in the largest metropolitan area of Massachusetts. We also sought to measure the change in uncompensated care following the implementation of MHR. We performed a retrospective review of all patients treated by the orthopaedic trauma services at three of the four level-I trauma centers in Boston from 2003 to 2010. The primary study cohort consisted of all uninsured patients, while the remaining patients were considered to have insurance. The study population was divided into two groups to compare the uninsured rate before and after MHR. Patients from 2006 to 2007 were excluded from the analysis to allow for an enrollment period in subsidized health insurance. A total of 16,338 patients with extremity and pelvic fractures and dislocations were treated from 2003 to 2010. There was a significant decrease in the uninsured rate from 23.8% to 14.4% following MHR (p < 0.001). The post-MHR risk of being uninsured is approximately 0.6 times the pre-MHR risk, with a 95% confidence interval of 0.56 to 0.65. There was also a reduction in the proportion of uncompensated care from 16.7% to 11.5% after MHR. There was an estimated 40% reduction in risk of uninsured individuals in the orthopaedic trauma population in the metropolitan Boston area following MHR. Despite a significant improvement, these results reveal a rate of uninsured individuals fivefold greater than currently reported by the state of Massachusetts and the U.S. government. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.
Holderried, Martin; Schlipf, Madeleine; Höper, Ansgar; Meier, Reinhard; Stöckle, Ulrich; Kraus, Tobias Maximilian
Background The use of information technology (IT) in health care has continuously increased. This includes software solutions for digitalisation, data storage and innovative approaches in diagnostics. The facilitation of the access to specific information, even by the patient, has changed daily clinical work. Patients inform themselves about symptoms, diagnostic methods and treatment options. This urge for information and the wish for the best treatment is summarised in the expression "patient empowerment". In some countries, the gap between do-it-yourself diagnosis and telemedicine via the telephone has already been closed. A sophisticated telemedical hotline may help to improve consultation and treatment of patients living in remote regions or rural communities. Traumatology telemedicine may also be used in trauma environments, such as disasters or mass casualties. Therefore, the purpose of this study was to assess the demand for e-health solutions among patients seeking the help of the emergency department in a trauma hospital. Methods A total of 255 patients (age range 18 - 75 years) were included in the study and were surveyed with the use of a questionnaire. As regards personal data, the questionnaire asked the patient about their Internet habits and about interesting topics they had researched in the world wide web. However, the questionnaire was specifically designed to ask for potential benefits and the patient's expectations for e-health solutions. Expected weaknesses and procedures for telemedical services were also included in a subsection. Results 43.5% of the patient cohort were woman and 56.5% men. The average distance to the hospital was 39.86 km. 223 patients were insured by the governmental health service providers and 32 had private insurance coverage. Aside from online shopping and online banking, the search for health topics was most frequent. The greatest fear was the lack of personal contact to the doctor (71.2%). Patients were also
Wang, Jing-bo; Jin, Hong-bin
The treatment of severely traumatic patients was changing from total care treament to the damage control surgery, as a result in the inflammatory reaction caused by trauma, in which the inflammatory marks, such as interleukin-6 and serum procalcitonin in the blood increased, and caused hypothermia, acidosis, and disturbance of blood coagulation, and resulted in the acute respiratory distress syndrome and multiple organs failure. A long-term operation as the second hit made the disease worse. In the patients, the femoral fracture was treated with external fixator; the pelvic fracture was treated with external fixator, and the uncontrolled haemorrhage in the pelvis was treated through direct hemostasis, angiography and embolism of arteries, and the tamponade of pelvis; the purpose of treatment of spinal fracture was keeping the stability of spine, avoiding the secondary injury on the spinal cord. It must pay attention to the injury of the adjacent organs and infection in the opening spinal injury. The result of operation was better in the incomplete spinal cord injury.
Piolanti, N; Nesti, A; Andreani, L; Parchi, P D; Cervi, V; Castellini, I; Marchetti, S
It is widely known that in Orthopaedics, as in each specialty, the academic influence of an article is also determined by the number of times the article is cited. The aim of this study was to identify the 50 most frequently cited Italian orthopaedics journal articles and to analyse the characteristics that might have made them more citable. Science Citation Index Expanded was searched for the 50 most frequently cited Italian orthopaedics journal articles between 1988 and 2013 in the subject category "Orthopaedics". The 50 most frequently cited articles were all published in English and were published in 12 of the 67 journals in the subject category "Orthopaedics" in the Institute for Scientific Information Web Science (Thomson Reuters, New York, New York, USA). One half of the articles were published before 2000 and the other half later. The number of citations ranged from 423 of the first article (mean citation/years 21.15) to 83 of the fiftieth (mean citation/years 16.60). The articles were all categorized under orthopaedic field, but each of them spanned from orthopaedics to a specific sub-specialty. The majority was clinical articles (n = 39), and the most common fields were sport orthopaedic surgery (including arthroscopy and cartilage) (n = 19) and biomechanics (n = 12). This list of 50 most frequently cited Italian articles is, to our knowledge, significantly important for the general orthopaedic scientific community, particularly for the Italian orthopaedic community. Researchers and doctors may use this work to make their future publications more influential and citable.
Jacoby, Sidney M; Herman, Martin J; Morrison, William B; Osterman, A Lee
Radiographic interpretation of pediatric elbow trauma presents a daunting task for both the radiologist and treating orthopaedic surgeon. Proper radiographic diagnosis and appropriate intervention requires a thorough understanding and appreciation of developmental anatomy. As the pediatric elbow matures, it transitions from multiple cartilaginous anlagen through a predictable pattern of ossification and fusion. When children sustain trauma to the elbow, they may have a limited capacity to communicate specific complaints and are sometimes difficult to examine reliably. Furthermore, the presence of multiple growth centers, and their variability, makes radiographic evaluation of pediatric elbow injuries particularly challenging. These variables, coupled with the known adverse long-term sequelae of pediatric elbow trauma (painful nonunion, malunion, elbow stiffness, growth disturbance, etc.) highlight the importance of accurate radiographic interpretation, which facilitates appropriate treatment. By using an orderly, systematic approach based on well-defined anatomical relationships and accepted radiographic markers, the radiologist may effectively interpret and communicate pertinent findings to the treating orthopaedic surgeon. Furthermore, using common classification systems may facilitate interdisciplinary communication. Finally, it is crucial that caregivers of children consider the possibility of child abuse in suspect cases.
Kuang, Shaolong; Leung, Kwok-sui; Wang, Tianmiao; Hu, Lei; Chui, Elvis; Liu, Wenyong; Wang, Yu
Image guided navigation systems (IGNS) have been implemented successfully in orthopaedic trauma surgery procedures because of their ability to help surgeons position and orient hand-held drills at optimal entry points. However, current IGNS cannot prevent drilling tools or instruments from slipping or deviating from the planned trajectory during the drilling process. A method is therefore needed to overcome such problems. A novel passive/active hybrid robot (the HybriDot) for positioning and supporting surgical tools and instruments while drilling and/or cutting in orthopaedic trauma surgery is presented in this paper. This new robot, consisting of a circular prismatic joint and five passive/active back-drivable joints, is designed to fulfill clinical needs. In this paper, a system configuration and three operational modes are introduced and analyzed. Workspace and layout in the operating theatre (OT) are also analyzed in order to validate the structure design. Finally, experiments to evaluate the feasibility of the robot system are described. Analysis, simulation, and experimental results show that the novel structure of the robot can provide an appropriate workspace without risk of collision within OT environments during operation. The back-drivable joint mechanism can provide surgeons with more safety and flexibility in operational modes. The mean square value of the positional accuracy of this robot is 0.811 mm, with a standard deviation (SD) of 0.361 mm; the orientation is accurate to within 2.186º, with a SD of 0.932º. Trials on actual patients undergoing surgery for distal locking of intramedullary nails were successfully conducted in one pass using the robot. This robot has the advantages of having an appropriate workspace, being well designed for human-robot cooperation, and having high accuracy, sufficient rigidity, and easy deployability within the OT for use in common orthopaedic trauma surgery tasks such as screw fixation and drilling assistance
Singh, Jagwant; Onimowo, Jemina O; Khan, Wasim S
Bone tissue engineering is a promising therapeutic option to enhance tissue regeneration and repair. The development of bone tissue engineering is directly related to changes in materials technology. While the inclusion of material requirements is standard in the design process of engineered bone substitutes, it is critical to incorporate clinical requirements in order to engineer a clinically relevant device. This review focuses on the potentials of bone marrow derived mesenchymal stem cells (BM-MSCs) in trauma and orthopaedics and presents the need for bone tissue-engineered alternatives.
Baumgartner, Rita; Libuit, Kiley; Ren, Dennis; Bakr, Omar; Singh, Nathan; Kandemir, Utku; Marmor, Meir Tibi; Morshed, Saam
The use of fluoroscopy for indirect guidance in orthopaedic trauma surgery has increased. The purpose of this investigation was to assess how real-time visualization of radiation exposure impacts dose levels during orthopaedic trauma operations. Observational comparative study. Level 1 trauma center orthopaedic trauma surgery operating room. The participants in this study were 83 patients with fractures of the ankle, tibia, femur, or acetabulum receiving definitive surgical fixation of their fracture; children under 18 years of age were excluded from the study. Fellowship trained orthopaedic trauma surgeons, resident orthopaedic surgeons, radiology technicians, and scrub nurses involved in the operations on included fracture patients were also participants. Real-time radiation exposure feedback from the Philips DoseAware device. Radiation exposure from fluoroscopy compared between phase 1, during which participants were blinded to exposure levels, and phase 2, during which participants were able to see exposure levels in real time. Overall mean radiation exposure was decreased by 60% in phase 2 compared with phase 1 (P = 0.023). Mean surgeon (MS; average of primary and assistant surgeon) and mean nonsurgeon personnel (average of x-ray technician, scrub nurse, and patient) radiation exposures were decreased from phase 1 to phase 2, by 58% and 80%, respectively (MS, P = 0.034; mean nonsurgeon personnel, P = 0.043). From phase 1 to phase 2, MS radiation for femoral shaft fractures decreased by 80% or 162.0 μSv (P = 0.02) and by 81% or 128.9 μSv (P = 0.014) for acetabular fractures. Our data demonstrate that real-time visualization of radiation exposure during orthopaedic trauma operations can decrease radiation exposure in the highest exposure cases. Further research is necessary to determine whether the reduction in radiation exposure is sustained over time and to understand how real-time radiation exposure data mitigates exposure. Therapeutic Level III. See
Mooij, S C; Antony, P; Ruesseler, M; Pfeifer, R; Drescher, W; Simon, M; Pape, H-C; Knobe, M
Due to recent changes in the medical licencing act as well as to the introduction of a new model-course programme for medical studies, careers in medicine have become increasingly more attractive. However, there is still a dramatic shortage in younger generation physicians, especially within the surgical fields. The goal of this cross-sectional study was the gender-specific assessment of the ideal career wishes of students during medical school, with a focus being placed in orthopaedic trauma surgery. During the winter semester of 2010/2011 an online questionnaire (www.surveymonkey.com) was created for students enrolled in their 3rd to 12th semester (n=887). The questionnaire consisted of 50 questions [Likert scale (LS); 5 = agree, 1 = disagree] along with 10 free response questions. The scope of these questions ranged from personal career goals, within the context of their learning environment, to general life goals and planning. With regard to career choice, a differentiation was made between students' ideal career choices/subjects (IS), which were based solely on personal affinity, and so-called reality-based subjects (RS), which students considered more practical and to which they were more likely to apply in the future. The response rate was 36,4% (n=323, 23,4 years, 6.3 semesters, 226 [70.0%] female [f] and 97 [30.0%] male [m]). A total of 206 students (63.8%; m=55.7% vs. f=66.7%; p=0.047) were able to pinpoint an IS, this percentage increased with increasing semester number (p=0.048). Overall, 29.1% of students indicated that their IS lay in the field of orthopaedic trauma, while 20.0% of men and 19.1% of women saw it as a realistic career path (RS). Throughout the course of their studies, from the 3rd semester to their practical year, a declining tendency was observed regarding the agreement between ideal and realistic career paths. Particularly evident was a decreasing interest in the field of orthopaedic trauma, beginning around the 9th semester and
Boutefnouchet, Tarek; Budair, Basil
Objectives: This study aimed to identify how undergraduate students perceive learning opportunities available to them and to determine whether students with an interest in trauma and orthopaedic (T&O) surgery have different perceptions and attitudes towards learning. Methods: All fourth year medical students from the University of Birmingham Medical School (UK) were surveyed regarding their career intentions and their attitudes towards the teaching received in trauma and orthopaedic surgery. The questionnaire was designed to capture student perception of learning environments, core knowledge and career motivations. Results: Of the 157 respondents, 35 (22.3%) expressed an interest in a career in trauma and orthopaedic surgery. Medical students who reported educational value for trauma and orthopaedic surgery revealed that bedside teaching with a consultant was perceived extremely useful by 57.8% (n = 89). A similar ranking was awarded to small group teaching seminars and bedside teaching with a junior doctor or trainee by 54.5% (n = 85) and 51.6% (n = 79) of students, respectively. In contrast, trauma meetings and operating theatre learning environments were perceived to be of low educational value. Seeing patients within the clinical setting and the quality of teaching received were reported as the most motivating factors in career interest towards trauma and orthopaedic surgery, rated 43.9% (n = 69) and 35% (n = 55), respectively. Conclusions: Perceptions of educational benefit derived from each learning environment vary among undergraduate medical students. Overall the most valuable learning environment perceived by the students is formal patient-based teaching. Despite diverging speciality choices students demonstrate similar learning needs. PMID:28176671
Boutefnouchet, Tarek; Budair, Basil
This study aimed to identify how undergraduate students perceive learning opportunities available to them and to determine whether students with an interest in trauma and orthopaedic (T&O) surgery have different perceptions and attitudes towards learning. All fourth year medical students from the University of Birmingham Medical School (UK) were surveyed regarding their career intentions and their attitudes towards the teaching received in trauma and orthopaedic surgery. The questionnaire was designed to capture student perception of learning environments, core knowledge and career motivations. Of the 157 respondents, 35 (22.3%) expressed an interest in a career in trauma and orthopaedic surgery. Medical students who reported educational value for trauma and orthopaedic surgery revealed that bedside teaching with a consultant was perceived extremely useful by 57.8% (n = 89). A similar ranking was awarded to small group teaching seminars and bedside teaching with a junior doctor or trainee by 54.5% (n = 85) and 51.6% (n = 79) of students, respectively. In contrast, trauma meetings and operating theatre learning environments were perceived to be of low educational value. Seeing patients within the clinical setting and the quality of teaching received were reported as the most motivating factors in career interest towards trauma and orthopaedic surgery, rated 43.9% (n = 69) and 35% (n = 55), respectively. Perceptions of educational benefit derived from each learning environment vary among undergraduate medical students. Overall the most valuable learning environment perceived by the students is formal patient-based teaching. Despite diverging speciality choices students demonstrate similar learning needs. © The Authors, published by EDP Sciences, 2017.
Cunningham, Brian P; Swanson, David C; Basmajian, Hrayr; McLemore, Ryan; Ortega, Gilbert
The goal of this study was to examine the factors that affect career satisfaction in orthopaedic traumatologists. We hypothesize that the level of stress and career satisfaction in orthopaedic traumatology would be affected by increased number of call nights and work hours. A 30-question survey was emailed to members of the OTA. The survey evaluated 5 critical areas: training/experience, practice characteristics, demands, stress management strategies, and satisfaction. After approval by the OTA research committee, all active and associate US members of the OTA were contacted. The survey was open to the OTA members from July through November of 2012. Of 1031 members of the OTA, 263 members responded for an overall response rate of 25.5%. Most respondents were fellowship-trained (218, 82.9%) and predominantly young (<5 years in practice, 34.4%) or established surgeons (>15 years in practice, 28.5%). Most surgeons were married (229, 87.1%) and have not been divorced (226, 85.9%). Career satisfaction was statistically improved by belonging to larger practice (P = 0.016), decreased by work for more hours per week (P = 0.001), and improved by taking more call (P = 0.014). Career satisfaction among orthopaedic trauma surgeons was extremely high. Our results indicate that young surgeons may improve their job satisfaction and potentially prolong their career by limiting the numbers of hours worked, taking a consistent number of calls and joining a larger group. Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.
Lefaivre, Kelly A; Guy, Pierre; O'Brien, Peter J; Blachut, Piotr A; Shadgan, Babak; Broekhuyse, Henry M
To determine the 20 most cited articles and authors in the Journal of Orthopaedic Trauma during the first 20 years of publication, 1987 to 2007. Review. We used Web of Science "cited reference search" to determine the most cited articles originating in the Journal of Orthopaedic Trauma from 1987 to 2007, the first 20 years of publication. The characteristics of each article were recorded. Next, we manually searched each author's citations for works in the same time period to determine the most cited authors. The number of first authorships for each author was then determined using Medline, and a relative citation impact ratio was calculated. Finally, citation reports for the journal overall were created to evaluate the citation impact of the journal over the last 10 years. The top cited articles ranged from 64 to 566 citations with two articles over 100. Fifteen were clinical articles with the most common topic being tibia fractures (shaft, plateau, and pilon). The top cited authors ranged for 111 to 566 citations, whereas the citations per lead authorship ratio for the authors on that list ranged from 9.5 to 566 citations per lead authorship. The number of citations to the Journal of Orthopaedic Trauma overall over the last 20 years has increased from 181 in 1997 to 3050 in 2007. The influence of the Journal of Orthopaedic Trauma, its articles, and its authors is readily apparent in this review of the most cited articles and authors in the journal over its first 20 years of publication. This journal is a source of highly cited original articles and the work of many highly cited leaders in the field of orthopaedic trauma.
Issar, Neil M; Kadakia, Rishin J; Tsahakis, James M; Yoneda, Zachary T; Sethi, Manish K; Mir, Hassan R; Archer, Kristin; Obremskey, William T; Jahangir, Amir A
This study will evaluate whether or not texting frequency while driving and/or texting frequency in general are associated with an increased risk of incurring a motor vehicle collision (MVC) resulting in orthopaedic trauma injuries. All patients who presented to the Vanderbilt University Medical Center Orthopaedic Trauma Clinic were administered a questionnaire to determine background information, mean phone use, texting frequency, texting frequency while driving, and whether or not the injury was the result of an MVC in which the patient was driving. 237 questionnaires were collected. 60 were excluded due to incomplete date, leaving 57 questionnaires in the MVC group and 120 from patients with non-MVC injuries. Patients who sent more than 30 texts per week ("heavy texters") were 2.22 times more likely to be involved in an MVC than those who texted less frequently. 84% of respondents claimed to never text while driving. Dividing the sample into subsets on the basis of age (25 years of age or below considered "young adult," and above 25 years of age considered "adult"),young, heavy texters were 6.76 times more likely to be involved in an MVC than adult non-heavy texters (p = 0.000). Similarly, young adult, non-heavy texters were 6.65 (p = 0.005) times more likely to be involved in an MVC, and adult, heavy texters were 1.72 (p = 0.186) times more likely to be involved in an MVC. Patients injured in an MVC sent more text messages per week than non-MVC patients. Additionally, controlling for age demonstrated that young age and heavy general texting frequency combined had the highest increase in MVC risk, with the former being the variable of greatest effect.
Issar, Neil M.; Kadakia, Rishin J.; Tsahakis, James M.; Yoneda, Zachary T.; Sethi, Manish K.; Mir, Hassan R.; Archer, Kristin; Obremskey, William T.; Jahangir, Amir A.
Abstract: Background: This study will evaluate whether or not texting frequency while driving and/or texting frequency in general are associated with an increased risk of incurring a motor vehicle collision (MVC) resulting in orthopaedic trauma injuries. Methods: All patients who presented to the Vanderbilt University Medical Center Orthopaedic Trauma Clinic were administered a questionnaire to determine background information, mean phone use, texting frequency, texting frequency while driving, and whether or not the injury was the result of an MVC in which the patient was driving. Results: 237 questionnaires were collected. 60 were excluded due to incomplete date, leaving 57 questionnaires in the MVC group and 120 from patients with non-MVC injuries. Patients who sent more than 30 texts per week (“heavy texters”) were 2.22 times more likely to be involved in an MVC than those who texted less frequently. 84% of respondents claimed to never text while driving. Dividing the sample into subsets on the basis of age (25 years of age or below considered “young adult,” and above 25 years of age considered “adult”),young, heavy texters were 6.76 times more likely to be involved in an MVC than adult non-heavy texters (p = 0.000). Similarly, young adult, non-heavy texters were 6.65 (p = 0.005) times more likely to be involved in an MVC, and adult, heavy texters were 1.72 (p = 0.186) times more likely to be involved in an MVC. Conclusions: Patients injured in an MVC sent more text messages per week than non-MVC patients. Additionally, controlling for age demonstrated that young age and heavy general texting frequency combined had the highest increase in MVC risk, with the former being the variable of greatest effect. PMID:23416747
Background Many (artificial) bone substitute materials are currently available for use in orthopaedic trauma surgery. Objective data on their biological and biomechanical characteristics, which determine their clinical application, is mostly lacking. The aim of this study was to investigate structural and in vitro mechanical properties of nine bone substitute cements registered for use in orthopaedic trauma surgery in the Netherlands. Methods Seven calcium phosphate cements (BoneSource®, Calcibon®, ChronOS®, Eurobone®, HydroSet™, Norian SRS®, and Ostim®), one calcium sulphate cement (MIIG® X3), and one bioactive glass cement (Cortoss®) were tested. Structural characteristics were measured by micro-CT scanning. Compression strength and stiffness were determined following unconfined compression tests. Results Each bone substitute had unique characteristics. Mean total porosity ranged from 53% (Ostim®) to 0.5% (Norian SRS®). Mean pore size exceeded 100 μm only in Eurobone® and Cortoss® (162.2 ± 107.1 μm and 148.4 ± 70.6 μm, respectively). However, 230 μm pores were found in Calcibon®, Norian SRS®, HydroSet™, and MIIG® X3. Connectivity density ranged from 27/cm3 for HydroSet™ to 0.03/cm3 for Calcibon®. The ultimate compression strength was highest in Cortoss® (47.32 MPa) and lowest in Ostim® (0.24 MPa). Young's Modulus was highest in Calcibon® (790 MPa) and lowest in Ostim® (6 MPa). Conclusions The bone substitutes tested display a wide range in structural properties and compression strength, indicating that they will be suitable for different clinical indications. The data outlined here will help surgeons to select the most suitable products currently available for specific clinical indications. PMID:21288333
Shulman, Brandon S; Marcano, Alejandro I; Davidovitch, Roy I; Karia, Raj; Egol, Kenneth A
Despite frequent complaints by orthopaedic trauma patients, to our knowledge there is no data regarding weather's effect on pain and function following acute and chronic fracture. The aim of our study was to investigate the influence of daily weather conditions on patient reported pain and functional status. We retrospectively examined prospectively collected data from 2369 separate outpatient visits of patients recovering from operative management of acute tibial plateau fractures, acute distal radius fractures, and chronic fracture nonunions. Pain and functional status were assessed using a visual analogue scale (VAS) and the DASH and SMFA functional indexes. For each visit date, the mean temperature, difference between mean temperature and expected temperature, dew point, mean humidity, amount of rain, amount of snow, and barometric pressure were recorded. Statistical analysis was run to search for associations between weather data and patient reported pain and function. Low barometric pressure was associated with increased pain across all patient visits (p=0.007) and for patients at 1-year follow-up only (p=0.005). At 1-year follow-up, high temperature (p=0.021) and high humidity (p=0.030) were also associated with increased pain. No significant association was noted between weather data and patient reported functional status at any follow-up interval. Patient complaints of weather influencing pain after orthopaedic trauma are valid. While pain in the immediate postoperative period is most likely dominated by incisional and soft tissue injuries, as time progresses barometric pressure, temperature, and humidity impact patient pain levels. Affirming and counseling that pain may vary based on changing weather conditions can help manage patient expectations and improve satisfaction. Copyright © 2016 Elsevier Ltd. All rights reserved.
Clough, J F Myles; Hitchcock, Kristin; Nelson, David L
PubMed is the free public Internet interface to the US National Library of Medicine's MEDLINE database of citations to medical scientific articles. Many orthopaedic surgeons use PubMed on a regular basis, but most orthopaedic surgeons have received little or no training in how to use PubMed effectively and express frustration with the experience. Typical problems encountered are data overload with very large numbers of returns to look through, failure to find a specific article, and a concern that a search has missed important papers. It is helpful to understand the system used to enter journal articles into the database and the classification of the common types of searches and to review suggestions for the best ways to use the PubMed interface and find sources for search teaching and assistance.
Matuszewski, Paul E; Costales, Timothy; Zerhusen, Timothy; Coale, Max; Mehta, Samir; Pollak, Andrew N; OʼToole, Robert V
Some have proposed that a so-called digital divide exists for orthopaedic trauma patients and that the clinical usefulness of the Internet for these patients is limited. No studies to date have confirmed this or whether patients would use a provided web resource. The hypotheses of this study were (1) a larger than expected percentage of trauma patients have access to the Internet and (2) if given access to a custom site, patients will use it. Prospective cohort. Level 1 regional trauma center. Patients who were 18 years or older with acute operative fractures participated in this study. Enrollment was initiated either before discharge or at initial outpatient follow-up. We conducted a survey of demographics, Internet usage, device type, eHealth Literacy, and intent to use the web site. Participants received a keychain containing the web address and a unique access code to our custom orthopaedic trauma web site. Percentage of patients with Internet access and percentage of patients who visited the web site. One hundred twelve patients were enrolled. Ninety-three percent (104/112) reported having Internet access (P < 0.0001). Only increasing age predicted lack of access (P < 0.015; odds ratio, 0.95). Most (95%, 106/112) planned to visit our site; however, only 11% (P < 0.001) accessed it. The digital divide is a myth in orthopaedic trauma. Despite widespread access and enthusiasm for our web site, few patients visited. This cautions against the allocation of resources for patient-specific web sites for orthopaedic trauma until a rationale for use can be better delineated. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Beebe, Allan C; Arnott, Lindsay; Klamar, Jan E; Kean, John R; Klingele, Kevin E; Samora, Walter P
Over the past decade, our institution has instituted three different scheduling models in an attempt to care for pediatric trauma at our Level I Trauma Center. This has been in response to a number of factors, including a limited number of physicians covering the call schedule, increasing competition for operating room (OR) time after hours (pediatric surgery, urology, neurosurgery), an attempt to fully utilize OR time during the daytime, fully staffed hours, and optimizing patients' timeliness to surgery. We examined the three on-call systems in place at our institution to determine whether a more flexible approach to pediatric trauma call resulted in delays in treatment. We retrospectively reviewed patient records for three distinct 1-year periods with three different surgical call schedules: (i) a traditional call schedule in which the call physician was responsible for patients who presented to our emergency room; (ii) a half-day trauma block OR reserved the morning following call; and (iii) a full-day trauma block. Variables included date of injury, time of admission, admission diagnosis, cause of injury, and OR procedure and start time. We reviewed 951 cases over the entire study, 268 during the traditional call schedule, 282 during the half-call block and 401 over the time period of the full-day block. Mechanisms of injury were similar among the three groups, with falls and motor vehicle accidents being the leading causes. The average delay time was 17:40 for the traditional call group, 15:10 for the half-block call group, and 15:09 for the full-day block group. Our findings suggest that there was a high incidence of cases performed on weekdays after peak staffing hours with a traditional call model (59%). In contrast, half-day and full-day block models saw only 4% and 1% of the cases performed after peak staffing hours, respectively. There was a statistically significant difference in the number of patients admitted to the OR among the three groups (χ(2
Calder, Andy; Badcoe, Andrew; Harms, Louise
The aim of this article is to present findings from an Australian study that explored road trauma survivors' perceptions of spirituality and of a hospital-based pastoral care service throughout their inpatient rehabilitation. All participants had experienced severe orthopaedic injury. A mixed-method research design was used. The survey method elicited demographic, pastoral care contact and hospitalisation data. It included the Posttraumatic Growth Inventory (PTGI; Tedeschi and Calhoun 1996) and an adapted World Health Organisation Pastoral Intervention (WHO 2002) coding schema (Constitution of the World Health Organisation, basic documents, supplement. 45 ed.). An interview method was used to elicit information about participants' prior and current experiences of faith and spirituality, expectations, and experiences of the pastoral care service, and perceptions of the role of pastoral care in their rehabilitation. A thematic analysis of both quantitative and qualitative data identified nine core themes of supportive pastoral care. Pastoral care was seen as a valued and supportive intervention. Participants who completed the PTGI reported at least some degree of posttraumatic growth. Further research is recommended to examine the role and efficacy of pastoral care that is integral to road trauma recovery support.
Moed, Berton R; Israel, Heidi A
The purposes of this study were to determine the current attitude of orthopaedic trauma surgeons toward device sales representatives (DSRs), especially regarding their presence in the operating room (OR), and to establish the existence of any surgeon generational differences. A survey was created using a 5-point Likert response scale, related to conflict of interest (COI) and attitudes toward DSRs. Participants were solicited from the Orthopaedic Trauma Association database of 384 active members and 127 (33%) completed the survey. Respondents were divided into 2 subcategories (Generation X vs. Baby Boomers). Overall, respondents viewed their DSRs favorably without any perception of COI. However, they perceived their peers as being at risk for COI (P ≤ 0.004). Generation X responders feel that DSRs should be in the OR for all cases, whereas Baby Boomers do not (P < 0.01). With one striking generational difference, most orthopaedic trauma surgeons feel that they need DSRs in the OR. Similar to other physician groups, they also feel that they are not subject to COI from salesman contact that affects their peers. Reasons for this perceived need and any related COI risk, and the opportunities to address both, require further study.
Eltorai, Adam E. M.; P. Thomas, Nathan; Yang, Heejae; Daniels, Alan H.; Born, Christopher T.
Context: According to the american medical association (AMA) and the national institutes of health (NIH), the recommended readability of patient education materials should be no greater than a sixth-grade reading level. The online patient education information produced by the american academy of orthopaedic surgeons (AAOS) may be too complicated for some patients to understand. This study evaluated whether the AAOS’s online trauma-related patient education materials meet recommended readability guidelines for medical information. Evidence Acquisition: Ninety-nine articles from the “Broken Bones and Injuries” section of the AAOS-produced patient education website, orthoinfo.org, were analyzed for grade level readability using the Flesch-Kincaid formula, a widely-used and validated tool to evaluate the text reading level. Results for each webpage were compared to the AMA/NIH recommended sixth-grade reading level and the average reading level of U.S. adults (eighth-grade). Results: The mean (SD) grade level readability for all patient education articles was 8.8 (1.1). All but three of the articles had a readability score above the sixth-grade level. The readability of the articles exceeded this level by an average of 2.8 grade levels (95% confidence interval, 2.6 - 3.0; P < 0.0001). Furthermore, the average readability of the articles exceeded the average reading skill level of U.S. adults (eighth grade) by nearly an entire grade level (95% confidence interval, 0.6-1.0; P < 0.0001). Conclusions: The majority of the trauma-related articles from the AAOS patient education website have readability levels that may make comprehension difficult for a substantial portion of the patient population. PMID:27218045
Karantanas, Apostolos H
MRI has been established as an essential tool for accurate diagnosis in patients with musculoskeletal trauma. Its major advantages include excellent soft tissue contrast, high spatial resolution and lack of ionizing radiation. Although plain radiographs remain the basic tool for diagnosis and treatment planning in bone fractures assisted by CT in pelvic, spine and large joints injuries, there are specific circumstances that require MRI. For instance, tendinous, ligamentous, intraarticular structures such as the cartilage and menisci, and intramedullary injury are seen mostly with MRI. Volumetric 3D techniques are now commercially available and provide higher spatial resolution which improves anatomic detail, allows multiplanar reformations and reduces the acquisition time. Newer applications on quantitative rather than morphologic imaging, such as relaxometry and diffusion tensor imaging, may be of paramount importance in treatment planning in the near future. Software improvements reduce metal induced artefacts, allowing thus imaging of the postoperative patient with metallic implants. A tendency towards a structured reporting pattern and standardised medical communication needs to be further explored for the benefit of orthopaedic surgeons, radiologists and patients. Copyright © 2014 Elsevier Ltd. All rights reserved.
Piorkowska, Marta; Al-Raweshidy, Zahra; Yeong, Keefai
Peripherally Inserted Central Catheter (PICC) blockage rate was audited over a two month period on the Trauma & Orthopaedics ward at our District General Hospital. A 70% (five out of seven) PICC blockage rate was observed. High blockage rates lead to potential treatment complications, delays in delivery of treatment, increase in costs, and reduction in patient satisfaction. The factors contributing to the significant blockage rate include, long and contradictory PICC care guidelines, no information sheets in the patient notes, lack of training and awareness about care of, and flushing of, PICC lines, and lack of accountability for PICC flushing. Our project aimed to achieve a greater rate of PICC patency. We produced one succinct and comprehensive PICC care guideline, carried out staff training sessions, introduced a sticker reminding staff to flush the PICC line after use, and introduced a prescription of weekly heparin saline and PRN saline flushes (for monitoring and accountability). We used questionnaires to assess competency of hospital staff pre-teaching (doctors 6%, nurses 0%), and post-teaching (doctors 70%, nurses 38%). Blockage rate data post-intervention is pending. Education improved awareness of guidelines amongst staff and we anticipate that the proposed interventions will translate into reduced blockage rates, improving patient outcomes and reducing costs.
Lee, Chang Hoon; Choi, Choong Hyeok; Yoon, Sang-Young; Lee, Jin Kyu
The aims of this prospective study were to determine the prevalence of posttraumatic stress disorder (PTSD) in a population of young male military conscripts who experienced an extremity long-bone fracture, and to evaluate whether injury-related variables are associated with the development of PTSD. Prospective, nonrandomized comparative study. Level 1 trauma center. A total of 148 men (age older than 18 years) who had 1 or more acute long-bone extremity fractures within 12 months and were seen at the Seoul Regional Military Manpower Center for examination of military conscripts from March 2013 to March 2014, were enrolled. The Korean version of the posttraumatic disorder scale was used to identify aspects of PTSD. The injury-related variables assessed included injury mechanism, fracture location and multiplicity, fracture severity, and the occurrence of joint ankylosis and secondary osteoarthritis. Of the 148 participants, 40 (27.0%) met the criteria for the diagnosis of PTSD. Multivariate logistic linear analysis confirmed that lower extremity fracture, multiple fractures, and a higher pain visual analog scale score were significantly (P = 0.042, P = 0.043 and P < 0.001, respectively) related to the occurrence of PTSD. Lower extremity fracture, multiple extremity fractures, and higher pain visual analog scale scores were significantly related to the occurrence of PTSD. To achieve an optimal recovery after orthopaedic injury, clinicians must address both physical and psychologic needs of their patients. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Basques, Bryce A; Gardner, Elizabeth C; Samuel, Andre M; Webb, Matthew L; Lukasiewicz, Adam M; Bohl, Daniel D; Grauer, Jonathan N
Alpine skiing and snowboarding are both popular winter sports that can be associated with significant orthopaedic injuries. However, there is a lack of nationally representative injury data for the two sports. The National Trauma Data Bank was queried for patients presenting to emergency departments due to injuries sustained from skiing and snowboarding during 2011 and 2012. Patient demographics, comorbidities, and injury patterns were tabulated and compared between skiing and snowboarding. Risk factors for increased injury severity score and lack of helmet use were identified using multivariate logistic regression. Of the 6055 patients identified, 55.2 % were skiers. Sixty-one percent had fractures. Lower extremity fractures were the most common injury and occurred more often in skiers (p < 0.001). Upper extremity fractures were more common in snowboarders, particularly distal radius fractures (p < 0.001). On multivariate analysis, increased injury severity was independently associated with age 18-29, 60-69, 70+, male sex, a positive blood test for alcohol, a positive blood test for an illegal substance, and wearing a helmet. Lack of helmet use was associated with age 18-29, 30-39, smoking, a positive drug test for an illegal substance, and snowboarding. Young adults, the elderly, and those using substances were shown to be at greater risk of increased injury severity and lack of helmet use. The results of this study can be used clinically to guide the initial assessment of these individuals following injury, as well as for targeting preventive measures and education. Prognostic Level III.
Sathiyakumar, Vasanth; Molina, Cesar S; Thakore, Rachel V; Obremskey, William T; Sethi, Manish K
Our purpose was to identify the impact of the physical status of the American Society of Anesthesiologists (ASA) on the 30-day readmission of patients receiving operative management of orthopaedic fractures using the National Surgical Quality Improvement Program (NSQIP) database. We analyzed all patients with orthopaedic trauma injuries in the American College of Surgeons NSQIP database from 2005 to 2011. A total of 8761 patients representing 91 orthopaedic trauma procedures were identified and included in analysis after selection. Logistic regressions were conducted to identify the predictive ability of ASA on the likelihood of readmission for patients in each anatomic category (upper extremity, pelvis/acetabulum, lower extremity) and the combined study population. The ASA physical status proved the strongest predictor of 30-day readmission for the selected orthopaedic trauma procedures. After controlling for age, gender, race, and medical comorbidities that were shown to be significant independent risk factors for readmission, ASA score continued to have a significant association on 30-day readmissions in the combined population (odds ratio = 1.45, 95% confidence interval = 1.13-1.88, P = 0.001). For the combined analysis, compared with patients with an ASA score of 1, patients with an ASA score of 2 were 1.04 times as likely to have a readmission (P = 0.001), patients with an ASA score of 3 were 3.77 times as likely to have a readmission (P = 0.001), and patients with an ASA score of 4 were 13.7 times as likely to have a readmission (P = 0.001). ASA classification is an indicator for variance in readmission for patients receiving operative treatment of orthopaedic fractures. Given that ASA classification is a universally collected data point, this method can be used in almost any hospital system and for any operative service. This model may be used to more accurately predict a patient's postoperative course and the expected risk for readmission, such that
Osti, Michael; Steyrer, Johannes
Defensive medical practice represents an increasing concern in European countries and is reported to account for rising health care expenditures. Malpractice liability, current jurisdiction and the increasing claim for accountability appear to result in additional diagnostic requests with marginal clinical benefit. Investigations that evaluate the national Austrian prevalence and contextual principles and consequences of defensive medicine are lacking so far. Orthopaedic and trauma surgeons as well as radiologists from public hospitals in Austria were invited to complete a study questionnaire retrieving personal estimation of the quantity of patient contacts and defensive requests in a typical month, subjective judgement of medico-legal climate, evolving defensive trends, working time usage for defensive considerations and prior confrontations with malpractice liability claims. The prevalence of defensive medicine was found to be 97.7%. The average orthopaedic or trauma surgeon requests 19.6 investigations per month for defensive reasons, which represents 28% of all diagnostic examinations. High-quality imaging modalities and short-term admissions yield increasing defensive significance. Participants are confronted with 1.4 liability claims per month. During the treatment of high-risk patients, 81% of doctors request additional diagnostic procedures for defensive considerations. Expenditure of time for defensive practice amounts to 9.2 hours/month in radiology and to 17 and 18% of total working time, respectively, in orthopaedic and trauma surgery. Defensive medical practice represents a serious and common challenge in Austria. Our results indicate the urgent necessity for confrontation with and solution for the increasing effort of self-protection within the health care system. © 2014 John Wiley & Sons, Ltd.
Kostuj, T; Kladny, B; Hoffmann, R
The register network of the German Society for Orthopaedics and Trauma (DGOU) consists of 14 registries that cover the various fields of traumatology and elective orthopedics. In addition to registries that focus on implants and types of diseases without age limitations, there are also registries dealing with special diseases in children and adolescents as well as the special needs of elderly patients with fractures. The registries serve as instruments for outcome research and quality assurance and can be used to develop treatment recommendations on a high level of evidence. The objective of the network is to exchange experience that facilitates the establishment of new registers, to pool expertise and to conserve resources.
Bin Abd Razak, Hamid Rahmatullah; Ang, Jin-Guang Ernest; Attal, Hersh; Howe, Tet-Sen; Allen, John Carson
"P-hacking" occurs when researchers preferentially select data or statistical analyses until nonsignificant results become significant. We wanted to evaluate if the phenomenon of p-hacking was evident in orthopaedic literature. We text-mined through all articles published in three top orthopaedic journals in 2015. For anonymity, we cipher-coded the three journals. We included all studies that reported a single p value to answer their main hypothesis. These p values were then charted and frequency graphs were generated to illustrate any evidence of p-hacking. Binomial tests were employed to look for evidence of evidential value and significance of p-hacking. Frequency plots for all three journals revealed evidence of p-hacking. Binomial tests for all three journals were significant for evidence of evidential value (p < 0.0001 for all). However, the binomial test for p-hacking was significant only for one journal (p = 0.0092). P-hacking is an evolving phenomenon that threatens to jeopardize the evidence-based practice of medicine. Although our results show that there is good evidential value for orthopaedic literature published in our top journals, there is some evidence of p-hacking of which authors and readers should be wary. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.
van Hove, Ruud P.; Sierevelt, Inger N.; van Royen, Barend J.; Nolte, Peter A.
Surfaces of medical implants can be enhanced with the favorable properties of titanium-nitride (TiN). In a review of English medical literature, the effects of TiN-coating on orthopaedic implant material in preclinical studies were identified and the influence of these effects on the clinical outcome of TiN-coated orthopaedic implants was explored. The TiN-coating has a positive effect on the biocompatibility and tribological properties of implant surfaces; however, there are several reports of third body wear due to delamination, increased ultrahigh molecular weight polyethylene wear, and cohesive failure of the TiN-coating. This might be due to the coating process. The TiN-coating process should be optimized and standardized for titanium alloy articulating surfaces. The clinical benefit of TiN-coating of CoCrMo knee implant surfaces should be further investigated. PMID:26583113
Ding, Min; Metcalfe, Helene; Gallagher, Olivia; Hamdorf, Jeffrey M
A review of the current literature evaluating trauma nursing education. A variety of trauma nursing courses exist, to educate nurses working in trauma settings, and to maintain their continuing professional development. Despite an increase in the number of courses delivered, there appears to be a lack of evidence to demonstrate the effectiveness of trauma nursing education and in particular the justification for this resource allocation. Integrative literature review. A search of international literature on trauma nursing education evaluation published in English from 1985 to 2015 was conducted through electronic databases CINAHL Plus, Google Scholar, PubMed, Austhealth, Science Citation Index Expanded (Web of Science), Sciverse Science Direct (Elsevier) & One file (Gale). Only peer reviewed journal articles identifying trauma course and trauma nursing course evaluation have been included in the selection criteria. An integrative review of both quantitative and qualitative literature guided by Whittemore and Knafl's theoretical framework using Bowling's and Pearson's validated appraisal checklists, has been conducted for three months. Only 17 studies met the inclusion criteria, including 14 on trauma course evaluation and 3 on trauma nursing course evaluation. Study findings are presented as two main themes: the historical evolution of trauma nursing education and evaluation of trauma nursing education outcomes. Trauma nursing remains in its infancy and education in this specialty is mainly led by continuing professional development courses. The shortage of evaluation studies on trauma nursing courses reflects the similar status in continuing professional development course evaluation. A trauma nursing course evaluation study will address the gap in this under researched area. Copyright © 2016 Elsevier Ltd. All rights reserved.
Althausen, Peter L; Shannon, Steven; Owens, Brianne; Coll, Daniel; Cvitash, Michael; Lu, Minggen; O'Mara, Timothy J; Bray, Timothy J
The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospitalbased PAs on orthopaedic trauma care at a level II community hospital. Retrospective case series. Level II trauma center. One thousand one hundred four trauma patients with orthopaedic injuries. PA involvement. Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients. At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P . 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0
Perkins, Crystal; Scannell, Brian; Brighton, Brian; Seymour, Rachel; Vanderhave, Kelly
The purpose of this study is to describe the epidemiology of orthopaedic injuries incurred secondary to firearms among children and adolescents at a major metropolitan trauma center and to identify risk factors for complications and long-term morbidity. A retrospective review was performed of consecutive patients 17 years of age and younger who sustained a firearm injury and required orthopaedic treatment at a major trauma center from 2006 to 2013. Patient demographics, injury mechanism, fracture classification, neurovascular injury, antibiotic administration, and length of hospitalization were recorded. Radiographic studies were used to determine fracture pattern, methods of stabilization, and time to union. Primary clinical outcomes include fracture nonunion, infection, and physeal arrest. 46 patients with a mean age of 12.7 years were treated for firearm related orthopaedic injuries. 72% of the patients were ages 13-17, while 28% were 12 years of age and younger. There were 28 violent injuries (21 assaults, 7 innocent bystanders) and 16 non-violent injuries (15 unintentional discharges and 1 self-inflicted). There was a bimodal distribution of violent versus nonviolent mechanisms, with the majority of children 12 years of age and under sustaining non-violent injuries and adolescents more commonly injured with a violent mechanism. There were 44 fractures and 6 traumatic arthrotomies, with eight associated neurovascular injuries. Twenty-five patients had an orthopaedic procedure, with a total of 43 surgeries. Mean hospital length of stay was 6.8 days. There were five deep infections. Four patients developed non-unions and all of these patients had deep infections. The timing and duration of antibiotic therapy was not significantly different between those who did and did not develop infection. Of the non-operatively treated fractures, there were no infections or non-unions at long-term follow-up. Morbidity and mortality related to firearms is a growing public
Patients with a history of traumatic life events can become distressed or re-traumatized as the result of healthcare experiences. These patients can benefit from trauma-informed care that is sensitive to their unique needs. However, despite the widespread prevalence of traumatic life experiences such as sexual assault and intimate partner violence, trauma-informed care has not been widely researched or implemented. The purpose of this synthesis of the literature is to examine existing research on trauma-informed care for survivors of physical and sexual abuse. The following themes are discussed: trauma screening and patient disclosure, provider-patient relationships, minimizing distress and maximizing autonomy, multidisciplinary collaboration and referrals, and trauma-informed care in diverse settings. This synthesis also explores implications for trauma-informed care research, practice and policy. The themes identified here could be used as a framework for creating provider and survivor educational interventions and for implementing trauma-informed care across disciplines. The findings of this synthesis support further research on patient and provider experiences of trauma-informed care, and research to test the efficacy of trauma-informed care interventions across healthcare settings. Universal implementation of trauma-informed care can ensure that the unique needs of trauma survivors as patients are met, and mitigate barriers to care and health disparities experienced by this vulnerable population.
Hiza, Elise A; Gottschalk, Michael B; Umpierrez, Erica; Bush, Patricia; Reisman, William M
The objective of this study is to analyze the effect of an orthopaedic trauma advanced practice provider on length of stay (LOS) and cost in a level I trauma center. The hypothesis of this study is that the addition of a single full-time nurse practitioner (NP) to the orthopaedic trauma team at a level I Trauma center would decrease overall LOS and hospital cost. A retrospective chart review of all patients discharged from the orthopaedic surgery service 1 year before the addition of a NP (pre-NP) and 1 year after the hiring of a NP (post-NP) were reviewed. Chart review included age, gender, LOS, discharge destination, intravenous antibiotic use, wound VAC therapy, admission location, and length of time to surgery. Statistical analysis was performed using the Wilcoxon/Kruskal-Wallis test. The hiring of a NP yielded a statistically significant decrease in the LOS across the following patient subgroups: patients transferred from the trauma service (13.56 compared with 7.02 days, P < 0.001), patients aged 60 years and older (7.34 compared with 5.04 days, P = 0.037), patients discharged to a rehabilitation facility (10.84 compared with 8.31 days, P = 0.002), and patients discharged on antibiotics/wound VAC therapy (15.16 compared with 11.24 days, P = 0.017). Length of time to surgery was also decreased (1.48 compared with 1.31 days, P = 0.37). The addition of a dedicated orthopaedic trauma advanced practice provider at a county level I trauma center resulted in a statistically significant decrease in LOS and thus reduced indirect costs to the hospital. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Patel, A D
This article introduces papers based on presentations from a symposium entitled "Bone Morphogenic Protein Advisory Meeting in Orthopaedic Trauma", where recent clinical findings with human bone morphogenetic protein-2 (rhBMP-2) were reviewed. It also presents two case studies which illustrate the clinical problems with the potential morbidity of tibial fractures and the potential benefits of the use of rhBMP-2 at surgery. The article concludes with a summary of the symposium. Tibial shaft fracture repair is associated with a significant financial burden on the patient, the health care providers and the medical insurance companies. It is anticipated that the clinical advantages of rhBMP-2 could lead to cost savings both inside and outside the hospital setting.
Doepfer, A-K; Seemann, R; Merschin, D; Stange, R; Egerth, M; Münzberg, M; Mutschler, M; Bouillon, B; Hoffmann, R
Patient safety has become a central and measurable key factor in the routine daily medical practice. The human factor plays a decisive role in safety culture and has moved into focus regarding the reduction of treatment errors and undesired critical incidents. Nonetheless, the systematic training in communication and interpersonal competences has so far only played a minor role. The German Society of Orthopaedics and Trauma (DGOU) in cooperation with the Lufthansa Aviation Training initiated a course system for interpersonal competence. Several studies confirmed the reduction of critical incidents and costs after implementation of a regular and targeted human factor training. The interpersonal competence should be an essential component of specialist training within the framework of a 3‑column model.
Jameson, S S; Lamb, A; Wallace, W A; Sher, J L; Marx, C; Reed, M R
Surgical trainees routinely provide evidence of their training and operative experience for assessment. National comparative data on the number of procedures performed during training was previously unavailable in the UK. Since 2003 every trainee in Trauma and Orthopaedics (T&O) in the UK and Ireland has submitted data recording their operative experience electronically via the Faculty of Health Informatics (FHI) eLogbook. This provides detailed data on trainee, trainer, hospital and training programme performance. This data has been analysed for trauma surgery. By March 2007 there were 1053 T&O Specialist Registrars with operations logged. Trauma operations performed and uploaded during the previous 3 years have been included. Each trainee's work is analysed by 'year-in-training' (YIT, 1-6). Data on levels of supervision and potentially missed opportunities (where the trainee was present but assisted rather than performed the operation) was analysed. The mean number of trauma operations performed annually by trainees was 109, 120, 110, 122, 98 and 84 (total 643) for YIT 1-6, respectively. 22% of the operations at which a trainee was present were potentially missed opportunities. A high level of experience is gained in hip fracture surgery (121 operations performed), intramedullary nailing (38) and ankle (47) stabilisation over the 6 years of training. However, the mean number of tendon repairs (18), tension band wires (13), external fixators (12) and children's supracondylar fracture procedures (9) performed is low. We also report figures for complex fracture stabilisation. The eLogbook remains a powerful tool which can provide accurate information to support in-depth analysis of trainees, trainers, and training programmes. Based on this analysis, we suggest 'standard setting' to identify trainees performing fewer operations than required during their training. We have also established a baseline which can be used to identify the consequences of changes to length
Rousseau, A-C; Blanchon, T; Turbelin, C; Cabane, J; Hanslik, T; Feron, J-M; Rousseau, B; Fardet, L
In France, primary-care physicians referring patients for admission can choose between public and private hospitals. The factors that govern their choices are unknown. Among all patient admissions reported from 1997 to 2011 by primary-care physicians participating in the Sentinels(®) network, we identified those due to orthopaedic conditions or trauma. We then identified the factors associated with referral to a private hospital rather than to a public hospital. Of 45,960 admissions reported to Sentinels(®) in 1997-2011, 2794 (6.1%) were for orthopaedic/trauma care. The main reasons for admission were hip fractures (27.5%), elective orthopaedic surgery (15.5%), fractures of the humerus (5.9%), wrist fractures (5.4%), soft-tissue lesions of the forearm or hand (5.0%), and spinal injuries (4.5%). Private hospitals were chosen more often for orthopaedic/trauma patients than for patients with other conditions (40% vs. 21.6% of cases, P<0.0001). When fracture of the humerus was used as the reference, referral to private hospitals was significantly more common for elective surgery (odds ratio, 3.30 [2.02-5.40]) and hip fracture (odds ratio, 1.50 [1.03-2.18]) and significantly less common for spinal injuries (odds ratio, 0.35 [0.19-0.66]). Other factors associated with referral to private hospitals were patient age, admission decision during an office visit or in a non-emergent setting, and admission decision made by the patient's usual physician. Specific factors seem to govern decisions by primary-care physicians to refer orthopaedic/trauma patients to private vs. public hospitals. Identical pricing scales for private and public hospitals will be implemented soon in France, a change that requires further analyses. Level IV. Copyright © 2013 Elsevier Masson SAS. All rights reserved.
Ying, Zhimin; Zhang, Min; Yan, Shigui; Zhu, Zhong
Clostridial myonecrosis is most often seen in settings of trauma, surgery, malignancy, and other underlying immunocompromised conditions. Since 1953 cases of gas gangrene have been reported in orthopaedic patients including open fractures, closed fractures, and orthopaedic surgeries. We present a case of 55-year-old obese woman who developed rapidly progressive gas gangrene in her right leg accompanied by tibial plateau fracture without skin lacerations. She was diagnosed with clostridial myonecrosis and above-the-knee amputation was carried out. This patient made full recovery within three weeks of the initial episode. We identified a total of 50 cases of gas gangrene in orthopaedic patients. Several factors, if available, were analyzed for each case: age, cause of injury, fracture location, pathogen, and outcome. Based on our case report and the literature review, emergency clinicians should be aware of this severe and potentially fatal infectious disease and should not delay treatment or prompt orthopedic surgery consultation.
Ying, Zhimin; Zhang, Min; Yan, Shigui; Zhu, Zhong
Clostridial myonecrosis is most often seen in settings of trauma, surgery, malignancy, and other underlying immunocompromised conditions. Since 1953 cases of gas gangrene have been reported in orthopaedic patients including open fractures, closed fractures, and orthopaedic surgeries. We present a case of 55-year-old obese woman who developed rapidly progressive gas gangrene in her right leg accompanied by tibial plateau fracture without skin lacerations. She was diagnosed with clostridial myonecrosis and above-the-knee amputation was carried out. This patient made full recovery within three weeks of the initial episode. We identified a total of 50 cases of gas gangrene in orthopaedic patients. Several factors, if available, were analyzed for each case: age, cause of injury, fracture location, pathogen, and outcome. Based on our case report and the literature review, emergency clinicians should be aware of this severe and potentially fatal infectious disease and should not delay treatment or prompt orthopedic surgery consultation. PMID:24288638
Popescu, Diana; Laptoiu, Dan
There has been a lot of hype surrounding the advantages to be gained from rapid prototyping processes in a number of fields, including medicine. Our literature review aims objectively to assess how effective patient-specific surgical guides manufactured using rapid prototyping are in a number of orthopaedic surgical applications. To this end, we carried out a systematic review to identify and analyse clinical and experimental literature studies in which rapid prototyping patient-specific surgical guides are used, focusing especially on those that entail quantifiable outcomes and, at the same time, providing details on the guides' design and type of manufacturing process. Here, it should be mentioned that in this field there are not yet medium- or long-term data, and no information on revisions. In the reviewed studies, the reported positive opinions on the use of rapid prototyping patient-specific surgical guides relate to the following main advantages: reduction in operating times, low costs and improvements in the accuracy of surgical interventions thanks to guides' personalisation. However, disadvantages and sources of errors which can cause patient-specific surgical guide failures are as well discussed by authors. Stereolithography is the main rapid prototyping process employed in these applications although fused deposition modelling or selective laser sintering processes can also satisfy the requirements of these applications in terms of material properties, manufacturing accuracy and construction time. Another of our findings was that individualised drill guides for spinal surgery are currently the favourite candidates for manufacture using rapid prototyping. Other emerging applications relate to complex orthopaedic surgery of the extremities: the forearm and foot. Several procedures such as osteotomies for radius malunions or tarsal coalition could become standard, thanks to the significant assistance provided by rapid prototyping patient-specific surgical
material not immediately available. Surrounding imperious: Loneliness surgical activity, Disaster context, Mass cal. 2.2.2 Surgical Tools: External...in patients with multiple injuries is effective, time saving and safe: J. Trauma 2005,59, 408-415.  Russel R., Jaicks, MD, Stephen M Cohn, MD
Luthi, François; Deriaz, Olivier; Vuistiner, Philippe; Burrus, Cyrille; Hilfiker, Roger
Workers with persistent disabilities after orthopaedic trauma may need occupational rehabilitation. Despite various risk profiles for non-return-to-work (non-RTW), there is no available predictive model. Moreover, injured workers may have various origins (immigrant workers), which may either affect their return to work or their eligibility for research purposes. The aim of this study was to develop and validate a predictive model that estimates the likelihood of non-RTW after occupational rehabilitation using predictors which do not rely on the worker's background. Prospective cohort study (3177 participants, native (51%) and immigrant workers (49%)) with two samples: a) Development sample with patients from 2004 to 2007 with Full and Reduced Models, b) External validation of the Reduced Model with patients from 2008 to March 2010. We collected patients' data and biopsychosocial complexity with an observer rated interview (INTERMED). Non-RTW was assessed two years after discharge from the rehabilitation. Discrimination was assessed by the area under the receiver operating curve (AUC) and calibration was evaluated with a calibration plot. The model was reduced with random forests. At 2 years, the non-RTW status was known for 2462 patients (77.5% of the total sample). The prevalence of non-RTW was 50%. The full model (36 items) and the reduced model (19 items) had acceptable discrimination performance (AUC 0.75, 95% CI 0.72 to 0.78 and 0.74, 95% CI 0.71 to 0.76, respectively) and good calibration. For the validation model, the discrimination performance was acceptable (AUC 0.73; 95% CI 0.70 to 0.77) and calibration was also adequate. Non-RTW may be predicted with a simple model constructed with variables independent of the patient's education and language fluency. This model is useful for all kinds of trauma in order to adjust for case mix and it is applicable to vulnerable populations like immigrant workers.
Müller, Marcus Christian; Frege, Sophie; Strauss, Andreas Christian; Gathen, Martin; Windemuth, Michael; Striepens, Eva Nadine
The objective was to evaluate whether the new intraoperative C-arm guiding system ClearGuide® (CG) reduces radiation exposure of the staff in an Orthopaedic and Trauma operation theatre. Data of 95 patients CG was used were retrospectively compared using matched-pair analysis with controls without CG. Radiation dose (RD), fluoroscopic time (FT) and operation time (OT) were analysed in ten types of operative procedures. Use of CG led to a significant reduction (p ≤ 0.05) of the RD in intramedullary nailing and plate fixation of femoral shaft fractures as well as plating of tibia shaft fractures. Concerning FT, use of CG led to a significant reduction (p ≤ 0.05) while performing kyphoplasties and plate fixation of femoral shaft fractures. Regarding OT, no statistical significance was observed. CG as a simple, reproducible and intuitive communication tool for C-arm guidance reduces intraoperative staff radiation exposure especially while fixation of long bone fractures and in spine surgery. Copyright © 2017 John Wiley & Sons, Ltd.
Implant-associated infections remain a major issue in orthopaedics and antimicrobial functionalization of the implant surface by antibiotics or other anti-infective agents have gained interest. The goal of this article is to identify antimicrobial coatings, for which clinical data are available and to review their clinical need, safety profile, and their efficacy to reduce infection rates. PubMed database of the National Library of Medicine was searched for clinical studies on antimicrobial coated implants for internal fracture fixation devices and endoprostheses for bone surgery, for which study design, level of evidence, biocompatibility, development of resistance, and effectiveness to reduce infection rates were analyzed. Four different coating technologies were identified: gentamicin poly(d, l-lactide) coating for tibia nails, one high (MUTARS(®)) and one low amount silver (Agluna) technology for tumor endoprostheses, and one povidone-iodine coating for titanium implants. There was a total of 9 published studies with 435 patients, of which 7 studies were case series (level IV evidence) and 2 studies were case control studies (level III evidence). All technologies were reported with good systemic and local biocompatibility, except the development of local argyria with blue to bluish grey skin discoloration after the use of silver MUTARS(®) megaendoprostheses. For the local use of gentamicin, there is contradictory data on the risk of emergence of gentamicin-resistance strains, a risk that does not seem to exist for silver and iodine based technologies. Regarding reduction of infection rates, one case control study showed a significant reduction of infection rates by Agluna silver coated tumor endoprostheses. Based on socio-economic data, there is a strong need for improvement of infection prevention and treatment strategies, including implant coatings, in fracture care, primary and revision arthroplasty, and bone tumor surgery. The reviewed gentamicin, silver
Luthi, François; Deriaz, Olivier; Vuistiner, Philippe; Burrus, Cyrille; Hilfiker, Roger
Background Workers with persistent disabilities after orthopaedic trauma may need occupational rehabilitation. Despite various risk profiles for non-return-to-work (non-RTW), there is no available predictive model. Moreover, injured workers may have various origins (immigrant workers), which may either affect their return to work or their eligibility for research purposes. The aim of this study was to develop and validate a predictive model that estimates the likelihood of non-RTW after occupational rehabilitation using predictors which do not rely on the worker’s background. Methods Prospective cohort study (3177 participants, native (51%) and immigrant workers (49%)) with two samples: a) Development sample with patients from 2004 to 2007 with Full and Reduced Models, b) External validation of the Reduced Model with patients from 2008 to March 2010. We collected patients’ data and biopsychosocial complexity with an observer rated interview (INTERMED). Non-RTW was assessed two years after discharge from the rehabilitation. Discrimination was assessed by the area under the receiver operating curve (AUC) and calibration was evaluated with a calibration plot. The model was reduced with random forests. Results At 2 years, the non-RTW status was known for 2462 patients (77.5% of the total sample). The prevalence of non-RTW was 50%. The full model (36 items) and the reduced model (19 items) had acceptable discrimination performance (AUC 0.75, 95% CI 0.72 to 0.78 and 0.74, 95% CI 0.71 to 0.76, respectively) and good calibration. For the validation model, the discrimination performance was acceptable (AUC 0.73; 95% CI 0.70 to 0.77) and calibration was also adequate. Conclusions Non-RTW may be predicted with a simple model constructed with variables independent of the patient’s education and language fluency. This model is useful for all kinds of trauma in order to adjust for case mix and it is applicable to vulnerable populations like immigrant workers. PMID:24718689
Holman, Joel E; Stoddard, Gregory J; Higgins, Thomas F
The prudent use of prescription opiate medications is a central aspect of postoperative pain management. The mortality associated with prescription opiate overdose is reaching epidemic proportions nationally, and is the leading cause of accidental death in greater than half the states in the United States. This study sought to determine the rates of preinjury opiate use in patients with orthopaedic trauma and the risk factors for prolonged use postinjury. The Utah Controlled Substance Database was queried to determine the use of prescription opiates by all patients admitted to the orthopaedic trauma service for a two-year period with isolated musculoskeletal injuries. Usage three months prior to injury and six months postinjury was examined. Six hundred and thirteen patients met inclusion criteria. Among patients with orthopaedic trauma, 15.5% had filled a prescription for opiates in the three months prior to injury, compared with 9.2% of the general population (p < 0.001). More than one prescription was filled by 12.2% of the patients with trauma preinjury compared with 6.4% of the general population (p < 0.001). Postoperatively, 68.4% of all patients filled opiate prescriptions for less than six weeks, 11.9% filled opiate prescriptions between six and twelve weeks, and 19.7% filled opiate prescriptions past twelve weeks. Patients with preinjury use of more than one opiate prescription in the three months preinjury were six times as likely to continue use past twelve weeks, and 3.5 times as likely to obtain opiates from a provider other than their surgeon (p < 0.001). Opiate use was briefest with upper-extremity injuries, followed by lower-extremity injuries and pelvic or acetabular injuries. Regression models demonstrate that risk factors for prolonged use of opiates include advancing age and extent of preinjury use. Patients with orthopaedic trauma are significantly more likely than the general population to use prescription opiates prior to injury. Preinjury
Romanò, Carlo Luca; Scarponi, Sara; Gallazzi, Enrico; Romanò, Delia; Drago, Lorenzo
Implanted biomaterials play a key role in current success of orthopedic and trauma surgery. However, implant-related infections remain among the leading reasons for failure with high economical and social associated costs. According to the current knowledge, probably the most critical pathogenic event in the development of implant-related infection is biofilm formation, which starts immediately after bacterial adhesion on an implant and effectively protects the microorganisms from the immune system and systemic antibiotics. A rationale, modern prevention of biomaterial-associated infections should then specifically focus on inhibition of both bacterial adhesion and biofilm formation. Nonetheless, currently available prophylactic measures, although partially effective in reducing surgical site infections, are not based on the pathogenesis of biofilm-related infections and unacceptable high rates of septic complications, especially in high-risk patients and procedures, are still reported.In the last decade, several studies have investigated the ability of implant surface modifications to minimize bacterial adhesion, inhibit biofilm formation, and provide effective bacterial killing to protect implanted biomaterials, even if there still is a great discrepancy between proposed and clinically implemented strategies and a lack of a common language to evaluate them.To move a step forward towards a more systematic approach in this promising but complicated field, here we provide a detailed overview and an original classification of the various technologies under study or already in the market. We may distinguish the following: 1. Passive surface finishing/modification (PSM): passive coatings that do not release bactericidal agents to the surrounding tissues, but are aimed at preventing or reducing bacterial adhesion through surface chemistry and/or structure modifications; 2. Active surface finishing/modification (ASM): active coatings that feature pharmacologically active
Andrew, Nadine E; Gabbe, Belinda J; Wolfe, Rory; Williamson, Owen D; Richardson, Martin D; Edwards, Elton R; Cameron, Peter A
To describe and identify predictors of 12-month outcomes of serious orthopaedic injuries due to sport and active recreation. Prospective cohort study with 12-month follow-up. Two Level 1 adult trauma centers in Victoria, Australia. A total of 366 adults admitted to two Level 1 trauma centers for an orthopaedic sport and active recreation injury between August 2003 and March 2006. Patients were captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), followed up at 12 months, and were free of moderate to severe disability prior to injury. Independent variables assessed for predictors of outcome were sporting group, age, sex, marital status, education level, Injury Severity Score, injury patterns, and head injury status. The 12-item Short Form Health Survey and maximum pain scores. At 12 months postinjury, 22.8% of patients reported moderate to severe physical disability, 12.1% reported moderate to severe mental health disability, and 11.1% reported moderate to severe pain. There were significant differences in physical outcomes between sporting groups, with motor and equestrian sports reporting the worst physical outcomes. Multivariate analysis indentified increasing age (P = 0.010) and patterns of injury (P = 0.040) as significant predictors of a poor physical outcome at 12 months. No significant independent predictors of outcome for mental health and maximum pain at 12 months were identified. Almost one-quarter of participants reported moderate to severe physical disability at 12 months postinjury. Increasing age and patterns of injury were found to be significant predictors of a poor physical outcome at 12 months.
Ruesseler, M; Froehlich, S; Mittelmeier, W; Walcher, F; Obertacke, U
The fusion of orthopaedic and trauma surgery into a combined specialty requires a new evaluation of postgraduate and undergraduate training. This study presents a structured analysis of the implementation possibilities for undergraduate training. After defining 3 implementation alternatives for both clinical training and last year electives, SWOT analyses were performed. RESULTS. The SWOT analysis demonstrates for each of these 6 implementation models the strengths, weaknesses, opportunities and threats. In order to strengthen undergraduate training in the “new” specialty all medical faculties should discuss and define their implementation concepts.
Lopes, Nahara R L; Eisenstein, Evelyn; Williams, Lúcia C A
To review the scientific literature on pediatric abusive head trauma as a form of physical abuse against infants and young children, highlighting the prevalence, signs and symptoms, consequences, risk factors for its occurrence, and prevention strategies. The MEDLINE, SciELO, LILACS, and Web of Science databases from 2001 to 2012 were reviewed, using the terms "shaken baby syndrome" and "abusive head trauma" in English, Spanish, and Portuguese. Pediatric abusive head trauma is defined as injury to the skull or intracranial contents of a infant or child younger than 5 years due to intentional abrupt impact and/or violent shaking. It occurs mainly in infants and children under 1 year of age, and may result in severe consequences, from physical or mental disabilities to death. Although there are specific signs for this form of abuse, they can be mistaken for common illnesses in children or accidental head injury; thus, clinical training of professionals involved in the assessment of cases to attain the correct diagnosis is crucial. Prevention strategies should include early identification of cases, as well as parental education on child development, especially on the infant's crying pattern. Considering the severity of abusive head trauma in children, it is critical that prevention strategies be implemented and evaluated in the Brazilian context. It is suggested that its incidence indicators be assessed at the national level. Copyright © 2013 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.
Sayana, M K; Ashraf, M; O'Byrne, J
Traditionally, the UK and Ireland have followed the same postgraduate surgical training of orthopaedic surgeons. Modernising medical careers (MMC) and European Working Time Directive (EWTD) have radically changed the way surgical training is delivered in the UK. In Ireland, however, the traditional structure of surgical training system continues with an emphasis to modernise the training with more objective assessment tools. The aim of this review is to highlight the current differences in the higher surgical training in Orthopaedics in the UK and Ireland.
García Santos, Esther; Soto Sánchez, Ana; Verde, Juan M; Marini, Corrado P; Asensio, Juan A; Petrone, Patrizio
Duodenal injuries constitute a challenge to the Trauma Surgeon, mainly due to their retroperitoneal location. When identified, they present associated with other abdominal injuries. Consequently, they have an increased morbidity and mortality. At best estimates, duodenal lesions occur in 4.3% of all patients with abdominal injuries, ranging from 3.7% to 5%, and because of their anatomical proximity to other organs, they are rarely an isolated injury. The aim of this paper is to present a concise description of the anatomy, diagnosis, surgical management and treatment of complications of duodenal trauma, and an analysis of complications and mortality rates of duodenal injuries based on a 46-year review of the literature. Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.
O'Haire, Marguerite E; Guérin, Noémie A; Kirkham, Alison C
Animals have a long history of inclusion in psychiatric treatment. There has been a recent growth in the empirical study of this practice, known as Animal-Assisted Intervention (AAI). We conducted a systematic review of the empirical literature on AAI for trauma, including posttraumatic stress disorder (PTSD). Ten studies qualified for inclusion, including six peer-reviewed journal articles and four unpublished theses. Participants were predominantly survivors of child abuse, in addition to military veterans. The presentation of AAI was highly variable across the studies. The most common animal species were dogs and horses. The most prevalent outcomes were reduced depression, PTSD symptoms, and anxiety. There was a low level of methodological rigor in most studies, indicating the preliminary nature of this area of investigation. We conclude that AAI may provide promise as a complementary treatment option for trauma, but that further research is essential to establish feasibility, efficacy, and manualizable protocols.
O'Haire, Marguerite E.; Guérin, Noémie A.; Kirkham, Alison C.
Animals have a long history of inclusion in psychiatric treatment. There has been a recent growth in the empirical study of this practice, known as Animal-Assisted Intervention (AAI). We conducted a systematic review of the empirical literature on AAI for trauma, including posttraumatic stress disorder (PTSD). Ten studies qualified for inclusion, including six peer-reviewed journal articles and four unpublished theses. Participants were predominantly survivors of child abuse, in addition to military veterans. The presentation of AAI was highly variable across the studies. The most common animal species were dogs and horses. The most prevalent outcomes were reduced depression, PTSD symptoms, and anxiety. There was a low level of methodological rigor in most studies, indicating the preliminary nature of this area of investigation. We conclude that AAI may provide promise as a complementary treatment option for trauma, but that further research is essential to establish feasibility, efficacy, and manualizable protocols. PMID:26300817
Shaunak, Shalin; Dhinsa, Baljinder S; Khan, Wasim S
Orthopaedic surgery lends itself well to advances in technology. An area of interest and ongoing research is that of the production of scaffolds for use in trauma and elective surgery. 3D printing provides unprecedented accuracy in terms of micro- and macro-structure and geometry for scaffold production. It can also be utilised to construct scaffolds of a variety of different materials and more recently has allowed for the construction of bio-implants which recapitulate bone and cartilage tissue. This review seeks to look at the various methods of 3DP, the materials used, elements of functionality and design, as well as modifications to increase the biomechanics and bioactivity of 3DP scaffolds.
Brennan, S A; Ní Fhoghlú, C; Devitt, B M; O'Mahony, F J; Brabazon, D; Walsh, A
Implant-associated infection is a major source of morbidity in orthopaedic surgery. There has been extensive research into the development of materials that prevent biofilm formation, and hence, reduce the risk of infection. Silver nanoparticle technology is receiving much interest in the field of orthopaedics for its antimicrobial properties, and the results of studies to date are encouraging. Antimicrobial effects have been seen when silver nanoparticles are used in trauma implants, tumour prostheses, bone cement, and also when combined with hydroxyapatite coatings. Although there are promising results with in vitro and in vivo studies, the number of clinical studies remains small. Future studies will be required to explore further the possible side effects associated with silver nanoparticles, to ensure their use in an effective and biocompatible manner. Here we present a review of the current literature relating to the production of nanosilver for medical use, and its orthopaedic applications. ©2015 The British Editorial Society of Bone & Joint Surgery.
Gans, Itai; Jain, Amit; Sirisreetreerux, Norachart; Haut, Elliott R; Hasenboehler, Erik A
The risk of postoperative surgical site infection after long bone fracture fixation can be decreased with appropriate antibiotic use. However, there is no agreement on the superiority of a single- or multiple-dose perioperative regimen of antibiotic prophylaxis. The purpose of this study is to determine the following: 1) What are the current practice patterns of orthopaedic trauma surgeons in using perioperative antibiotics for closed long bone fractures? 2) What is the current knowledge of published antibiotic prophylaxis guidelines among orthopaedic trauma surgeons? 3) Are orthopaedic surgeons willing to change their current practices? A questionnaire was distributed via email between September and December 2015 to 955 Orthopaedic Trauma Association members, of whom 297 (31%) responded. Most surgeons (96%) use cefazolin as first-line infection prophylaxis. Fifty-nine percent used a multiple-dose antibiotic regimen, 39% used a single-dose regimen, and 2% varied this decision according to patient factors. Thirty-six percent said they were unfamiliar with Centers for Disease Control and Prevention (CDC) antibiotic prophylaxis guidelines; only 30% were able to select the correct CDC recommendation from a multiple-choice list. However, 44% of surgeons said they followed CDC recommendations. Fifty-six percent answered that a single-dose antibiotic prophylaxis regimen was not inferior to a multiple-dose regimen. If a level-I study comparing a single preoperative dose versus multiple perioperative antibiotic dosing regimen for treatment of closed long bone fractures were published, most respondents (64%) said they would fully follow these guidelines, and 22% said they would partially change their practice to follow these guidelines. There is heterogeneity in the use of single- versus multiple-dose antibiotic prophylaxis for surgical repair of closed long bone fractures. Many surgeons were unsure of current evidence-based recommendations regarding perioperative antibiotic
El-Menyar, A; Asim, M; Zarour, A; Abdelrahman, H; Peralta, R; Parchani, A; Al-Thani, H
A structured research programme is one of the main pillars of a trauma care system. Despite the high rate of injury-related mortalities, especially road traffic accidents, in Qatar, little consideration has been given to research in trauma. This review aimed to analyse research publications on the subject of trauma published from Qatar and to discuss the progress of clinical research in Qatar and the Gulf Cooperation Council countries with special emphasis on trauma research. A literature search using PubMed and Google Scholar search engines located 757 English-language articles within the fields of internal medicine, surgery and trauma originating from Qatar between the years 1993 and 2013. A steep increase in the number of trauma publications since 2010 could be linked to the setting up of a trauma research centre in Qatar in 2011. We believe that establishing a research unit has made a major impact on research productivity, which ultimately benefits health care.
Iqbal, H J; Ponniah, N; Long, S; Rath, N; Kent, M
The primary aim of this study was to determine whether orthopaedic trauma patients receive appropriate antibiotic prophylaxis keeping in view the results of their MRSA screening. The secondary aim was to analyse the risk of developing MRSA surgical site infection with and without appropriate antibiotic prophylaxis in those colonized with MRSA. We reviewed 400 consecutive orthopaedic trauma patient episodes. Preoperative MRSA screening results, operative procedures, prophylactic antibiotics and postoperative course were explored. In addition to these consecutive patients, the hospital MRSA database over the previous 5 years identified 27 MRSA colonized acute trauma patients requiring surgery. Of the 400 consecutive patient episodes, 395(98.7%) had MRSA screening performed on admission. However, in 236 (59.0%) cases, the results were not available before the surgery. Seven patient episodes (1.8%) had positive MRSA colonization. Analysis of 27 MRSA colonized patients revealed that 20(74%) patients did not have the screening results available before the surgery. Only 5(18.5%) received Teicoplanin and 22(81.4%) received cefuroxime for antibiotic prophylaxis before their surgery. Of those receiving cefuroxime, five (22.73%) patients developed postoperative MRSA surgical site infection (SSI) but none of those (0%) receiving Teicoplanin had MRSA SSI. The absolute risk reduction for SSI with Teicoplanin as antibiotic prophylaxis was 22.73% (CI=5.22%-40.24%) and NNT (Number Needed to Treat) was 5 (CI=2.5-19.2) CONCLUSION: Lack of available screening results before the surgery may lead to inadequate antibiotic prophylaxis increasing the risk of MRSA surgical site infection. Glycopeptide (e.g.Teicoplanin) prophylaxis should be considered when there is history of MRSA colonization or MRSA screening results are not available before the surgery. Copyright © 2017. Published by Elsevier Ltd.
Kirouac, Samantha; McBride, Dawn Lorraine
This project provides a comprehensive overview of the research literature on the brain and how trauma impacts brain development, structures, and functioning. A basic exploration of childhood trauma is outlined in this project, as it is essential in making associations and connections to brain development. Childhood trauma is processed in the…
Thirumal, Vanushia; Love, Gavin
A high incidence of hypokalaemia was noted in Trauma and Orthopaedics of Ninewells Hospital. We sought to establish the reason behind this and implemented three PDSA cycles via questionnaires to 30 ward staff, both doctors and nurses over a 1 week period in December, February and July 2016. Key baseline measures include availability of IV fluids with 40mmol potassium on the wards, confidence prescribing or administering IV fluids with 40mmol potassium, necessity for cardiac monitoring during slow IV potassium replacement and recognition of confusion and learning need in this area. Interventions made include awareness and education session, departmental guideline, improving stock of IV fluids and hypokalaemia management pathway for mild, moderate and severe hypokalaemia. Post-intervention results showed 70% from 33% who said 40mmol IV potassium was available, 87% from 67% were confident prescribing or administering IV potassium and 70% from 27% were aware that cardiac monitoring was not necessary.
Thirumal, Vanushia; Love, Gavin
A high incidence of hypokalaemia was noted in Trauma and Orthopaedics of Ninewells Hospital. We sought to establish the reason behind this and implemented three PDSA cycles via questionnaires to 30 ward staff, both doctors and nurses over a 1 week period in December, February and July 2016. Key baseline measures include availability of IV fluids with 40mmol potassium on the wards, confidence prescribing or administering IV fluids with 40mmol potassium, necessity for cardiac monitoring during slow IV potassium replacement and recognition of confusion and learning need in this area. Interventions made include awareness and education session, departmental guideline, improving stock of IV fluids and hypokalaemia management pathway for mild, moderate and severe hypokalaemia. Post-intervention results showed 70% from 33% who said 40mmol IV potassium was available, 87% from 67% were confident prescribing or administering IV potassium and 70% from 27% were aware that cardiac monitoring was not necessary. PMID:28469890
Cooper, M Townsend; Szyld, Edgardo; Darden, Paul M
Anecdotal experiences raise concerns that abusive head trauma (AHT) is significantly underdiagnosed and perhaps poorly recognized in Latin American settings. With increasing interest in international collaboration in pediatrics, differences in perspectives regarding complex diagnoses should be explored to facilitate a productive exchange of knowledge and ideas. The purpose of this study was to describe the medical literature pertaining to AHT available to physicians who read only in Spanish. In this review, LILACS, SciELO (major Spanish language databases) and Pubmed were searched with appropriate terms and filters in English, Spanish, and Portuguese for Spanish language articles on AHT. Identified articles' reference lists were then examined for possible additional articles on AHT. All relevant articles were sorted by country and examined for article type and content. Thirty-four unique articles were located for review from 8 of 21 countries. Most of the articles identified were case reports, case series, or educational, and there were no studies regarding overall incidence or prevalence of AHT. Some scientific information contained in the articles varied considerably from that in the English language literature in the areas of etiology and preventive strategies. This survey highlights that the Spanish language literature regarding AHT is sparse and variable. This must be considered when working collaboratively in a global setting. Additionally, identification of this gap presents an opportunity for education and information exchange among global medical communities. Copyright © 2016 Elsevier Ltd. All rights reserved.
Mittlmeier, T; Bonnaire, F; Grützner, P A; Lill, H; Matthes, G; Prokop, A; Seifert, J; Voigt, C; Walcher, F; Wölfl, C; Siebert, H
The lack of clinical residents especially in the surgical domains, including orthopaedics and trauma surgery, is not only omnipresent but also a topic of lively discussions. This lack originates from sociopolitical and healthcare policy issues as well as from a loss of attractiveness of all surgical disciplines. The loss is caused by the high workload and disadvantageous working hours especially in those disciplines with a high rate of emergencies, e.g. trauma surgery. Moreover, it is caused by the poorly structured and unpredictable period of residency. In order to anticipate the bottleneck in supply due to the lack of trainees, a number of structural and contextual measures have to be taken to improve both undergraduate und postgraduate surgical training. Due to the numerous facets of the topic the first part of this analysis refers to the period until the trainee decides on the field of training.A basic insight into the field of orthopaedics and trauma surgery can already be offered far before the period of medical studies itself. During undergraduate medical education the existing structures should be modified, the characteristics of the discipline should be emphasized and the charm of combining theory and practical skills should be highlighted in order to enhance student's perception of the discipline. This might begin during preclinical training and should be continued throughout clinical training and elective courses (basic wound care, TEAM approach, AO course for students and seminars for M.D. candidates). Contextual and structural improvements of the practical year are indispensable to arouse students' interest in our discipline. These options conjoined with the actual offers for students provided by our scientific society, such as guided tours during the annual congress, travelling grants and the recently inaugurated summer school, might provide the basis for clearly structured information and offer a distinct stimulus to apply for residency in our field.
Dy, Christopher J; Dossous, Paul-Michel; Ton, Quang V; Hollenberg, James P; Lorich, Dean G; Lane, Joseph M
The purpose of the study is to evaluate the influence of a multidisciplinary model of care on the incidence of postoperative complications after a hip fracture. Retrospective cohort series. Level I trauma center. Three hundred six patients with pertrochanteric femur fracture (OTA classification: 31-B1, 31-B2, 31-B3, 31-A1, 31-A2, 31-B3, 32-A1, and 32-A2). A multidisciplinary, collaborative model of perioperative care: the Medical Orthopaedic Trauma Service (MOTS). Incidence of in-patient complications, length of in-patient hospitalization, readmission rate after hospital discharge, and postdischarge mortality at 90 days and 1 year. Although there was no change in length of hospitalization, there was a significantly decreased overall incidence of in-patient complications and a decreased incidences of new-onset urinary tract infection and arrhythmias in the MOTS cohort. These differences persisted after controlling for age, comorbidity, gender, ethnicity, type of fracture, and number of days from admission to surgery with a logistic regression model. Subgroup analysis of patients with an American Society of Anesthesiologists physical status classification of 1 or 2 revealed a significantly decreased 90 day readmission rate with the MOTS model, but this did not persist in a regression model (P = 0.07). A multidisciplinary, collaborative model of care for patients with hip fractures decreases the incidence of postoperative in-patient complications and may influence hospital readmission rates. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Holman, Joel E; Stoddard, Gregory J; Horwitz, Daniel S; Higgins, Thomas F
The prudent use of prescription opiates is a central aspect of current postsurgical pain management, but surgeons have no guidelines on appropriate duration of opiate treatment. Furthermore, there are no established data on the effect of physician counseling on the duration of opiate use postoperatively. Retrospective surgeon-controlled cohort study. Level I regional academic trauma center. All Utah residents admitted to the orthopaedic trauma service with isolated operative musculoskeletal injury. One group of patients was instructed at the time of index procedure that they would receive prescription opiates for a maximum of 6 weeks. The remaining patients were not counseled preoperatively on duration of opiate use postoperatively. The presence and frequency of prescription opiate use before injury, cessation of opiate use by 6 weeks postoperatively, cessation of opiates by 12 weeks postoperatively, and continuation of prescription opiates greater than 12 weeks postoperatively. Six hundred thirteen patients met inclusion criteria. Those counseled preoperatively to cease opiate use by 6 weeks were significantly more likely to do so than those who did not receive counseling (73% and 64%, respectively; P = 0.012). By 12 weeks, this effect was no longer seen, and patients were just as likely to have stopped (80% and 80%, respectively; P = 0.90). The orthopaedic trauma population is significantly more likely than the general population to be using prescription opiates before injury. Physician discussion of 6-week opiate prescription limitation at the time of injury seems to lead to a lower rate of use at the 6-week postoperative mark but has no effect on rates of longer-term use. Twenty percent of patients in either group will continue to use opiates after 12 weeks, compared with 15% before injury. Given the scope of prescription opiate use in the United States, surgeons may want to consider preoperative discussion of this issue, but it may not have any effect on usage
Mittlmeier, T; Bonnaire, F; Grützner, P A; Lill, H; Matthes, G; Prokop, A; Seifert, J; Voigt, C; Walcher, F; Wölfl, C; Siebert, H
An increasing lack of young fellowship trainees in operative medicine, particularly in orthopaedics and traumatology and the various options to counteract this problem during the phases until the individual decision for residency and the fellowship program is made, were the focus of part I. The present part concentrates on residency and the fellowship phase including the individual perspectives after successful training. With respect to an attractive and highly qualified training in orthopaedics and traumatology, three essential points are to be made: a timely general framework, the establishment of a clinic-specific management of training and a general evaluation of training in the sense of a benchmarking system. A flexible work schedule including structural entities, such as an in-hospital day care facility for children, a structured and reliable curriculum of training according to a model curriculum to be adapted to the corresponding training unit including options of rotation to other facilities of training and the integration of nationwide education and mentoring programs represent further elements of an attractive training program. Thus the quality of training will become a decisive criterion of selection. The fellowship program for specialized traumatology inevitably leads to limitations of the whole spectrum of the field with an increasing specialization. In the future the contents of fellowship training will need a well-considered adaptation to the clinical needs and realities in the light of the emerging national trauma network program. A wide field of activity will open up to specialists in orthopaedics and traumatology with a focus on special traumatology considering the rapid changing field of hospital and outpatient care. Thus a systematic and creative reorganization of the residency and fellowship phases will overcome any problem of attractiveness.
Ghazali, A. F.; Ismail, A. F.; Daud, A.
Detrimental effects of cigarette smoking have been well described and recognized globally. With recent advancement of technology, electronic cigarette has been introduced and gained its popularity and became a global trend, especially among young adults. However, the safety of the electronic devices remains debatable. This paper aimed to compile and review the reported cases of oro-facial trauma related to the usage of electronic cigarette devices. A literature search was conducted using PubMed/Medline in December 2016. The search terms used were a combination of “oral trauma”, “dental trauma”, “oral injury” and “electronic cigarette”. The search included all abstract published from the inception of the database until December 2016. Abstract that was written in English, case report, letter to editors, clinical and human studies were included for analysis. All selected abstract were searched for full articles. A total of 8 articles were included for review. All of the articles were published in 2016 with mostly case reports. The sample size of the studies ranged from 1 to 15 patients. Seven of the included articles are from United States of America and one from Mexico. Our review concluded that the use of electronic cigarette devices posed not only a safety concern but also that the devices were mostly unregulated. There should be a recognized authority body to regulate the safety and standard of the electronic devices.
Moroz, Paul J; Spiegel, David A
Road traffic crash-related death, injury, and chronic disability continue to be a major worldwide burden to drivers, pedestrians, and users of mass transit, especially in low- and middle-income countries (LMIC). Projections predict worsening of this burden, and while motorization of LMIC increases exponentially, a corresponding improvement in prehospital and acute in-hospital trauma care has not been seen. The WHO now has 2 programs that address different elements of this challenge, namely, the Violence and Injury Prevention department (prevention) and the Emergency and Essential Surgical Care project (treatment). Activities of Violence and Injury Prevention have included developing guidelines for prehospital and essential trauma care, whereas activities of the Emergency and Essential Surgical Care have included developing the Integrated Management of Emergency and Essential Surgical Care toolkit and a textbook, "Surgical Care at the District Hospital." Organized surgical institutions in high-income countries-trauma associations, university departments, surgical nongovernmental organizations, etc.-can benefit from the infrastructure and tools the WHO has developed to better address the deficits in surgical services to improve the equitable distribution of surgical care services and resources to LMIC.
Catapano, Michele; Albano, Domenico; Pozzi, Grazia; Accetta, Riccardo; Memoria, Sergio; Pregliasco, Fabrizio; Messina, Carmelo; Sconfienza, Luca Maria
During night and on weekends, in our emergency department there is no radiologist on duty or on call: thus, X-ray examinations (XR) are evaluated by the orthopaedic surgeon on duty and reported the following morning/monday by radiologists. The aim of our study was to examine the discrepancy rate between orthopaedists and radiologists in the interpretation of imaging examinations performed on patients in our tertiary level orthopaedic institution and the consequences of delayed diagnosis in terms of patient management and therapeutic strategy. We retrospectively reviewed all cases of discrepancy between orthopaedists and radiologists, which were categorized according to anatomical location of injury, initial diagnosis and treatment, change in diagnosis and treatment. We used the Chi square test to compare the frequencies of discrepancies between patients ≤14 and >14years of age. From January to December 2016, 19,512 patients admitted to our emergency department performed at least an imaging examination; among these patients, 13,561 underwent XR in absence of an attending radiologist. A discrepant diagnosis was found in 337/13,561 (2.5%; 184 males; mean age: 36.7±23.7, range 2-95); 151/337 (45%) discrepancies were encountered in the lower limbs, with ankle being the most common site of misdiagnosis (64/151), and 103/337 (30%) in the upper limbs, with the elbow being the most frequent site in this district (35/103). We found 293/337 false negatives (87%) and 44/337 false positives (13%), with 134 and 13 patients needing treatment change, respectively. We found 85/337 discrepancies (25%) in patients ≤14 years of age, and 252/337 (75%) in those >14years. The distribution of discrepancies per anatomic district was significantly different (P<0.001) in these two groups of patients. A low rate of discrepancy between orthopaedists and radiologists in evaluating images of patients admitted to our emergency department was found, although treatment change occurred in about
Ptaszkiewicz, Grzegorz; Majewski, Włodzimierz
The authors present a review of trauma in tourist and competitive cycling in Poland in comparison with reports in the literature. Groups of injuries are discussed with a focus on their frequency and threat to life and health. The authors present a case of a road cycler colliding with a car, his first aid, evacuation, and treatment at a hospital. This case, as well as accidents of other competitive cyclers, are analyzed by the authors to demonstrate ways of reducing trauma in cycling. Most importantly, competitive and tourist cyclers should always wear cycle helmets as they reduce head trauma, the main life-threatening trauma in this sport.
In orthopaedic and trauma surgery, the rapid evolution of biomedical research has fundamentally changed the perception of the musculoskeletal system. Here, the rigor of basic science and the art of musculoskeletal surgery have come together to create a new discipline -experimental orthopaedics- that holds great promise for the causative cure of many orthopaedic conditions. The Journal of Experimental Orthopaedics intends to bridge the gap between orthopaedic basic science and clinical relevance, to allow for a fruitful clinical translation of excellent and important investigations in the field of the entire musculoskeletal system.
Quante, M; Pauschert, R; Gogarten, W
Today the indication for thrombosis prophylaxis is a relevant and daily concern in orthopaedic surgery. Recently there are some changes concerning the German guidelines, which are approved by 27 German medical societies. For the first time the guidelines give distinct recommendations for the different indications, the kind of thrombosis prophylaxis and its duration. Some of the recommendations will lead to changes of both processes in outpatient and inpatient management. In parallel 2 new oral anticoagulants have been approved for the prevention of thromboembolic events after elective knee and hip replacement. Dabigatran is an oral thrombin inhibitor. Compared to enoxaparin it has a comparable profile of side effects and efficacy. Rivaroxaban is an oral Xa inhibitor which shows a significantly better efficacy compared to enoxaparin and no difference in side effects. The significant reduction of symptomatic thromboembolisms after elective knee and hip replacement was shown for rivaroxaban compared to enoxaparin in a pooled analysis of phase III data. This review discusses the main topics of the new German guideline and impact of the new oral anticoagulants on in- and outpatient treatment procedures.
Niemeyer, P; Albrecht, D; Andereya, S; Angele, P; Ateschrang, A; Aurich, M; Baumann, M; Bosch, U; Erggelet, C; Fickert, S; Gebhard, H; Gelse, K; Günther, D; Hoburg, A; Kasten, P; Kolombe, T; Madry, H; Marlovits, S; Meenen, N M; Müller, P E; Nöth, U; Petersen, J P; Pietschmann, M; Richter, W; Rolauffs, B; Rhunau, K; Schewe, B; Steinert, A; Steinwachs, M R; Welsch, G H; Zinser, W; Fritz, J
Autologous chondrocyte implantation (ACI) is an established and well-accepted procedure for the treatment of localised full-thickness cartilage defects of the knee. The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU) describes the biology and function of healthy articular cartilage, the present state of knowledge concerning therapeutic consequences of primary cartilage lesions and the suitable indication for ACI. Based on best available scientific evidence, an indication for ACI is given for symptomatic cartilage defects starting from defect sizes of more than three to four square centimetres; in the case of young and active sports patients at 2.5cm(2), while advanced degenerative joint disease needs to be considered as the most important contraindication. The present review gives a concise overview on important scientific background and the results of clinical studies and discusses the advantages and disadvantages of ACI. Non-systematic Review. Copyright © 2016 Elsevier B.V. All rights reserved.
Tan, S. L. E.
Stereoscopy was used in medicine as long ago as 1898, but has not gained widespread acceptance except for a peak in the 1930's. It retains a use in orthopaedics in the form of Radiostereogrammetrical Analysis (RSA), though this is now done by computer software without using stereopsis. Combining computer assisted stereoscopic displays with both conventional plain films and reconstructed volumetric axial data, we are reassessing the use of stereoscopy in orthopaedics. Applications include use in developing nations or rural settings, erect patients where axial imaging cannot be used, and complex deformity and trauma reconstruction. Extension into orthopaedic endoscopic systems and teaching aids (e.g. operative videos) are further possibilities. The benefits of stereoscopic vision in increased perceived resolution and depth perception can help orthopaedic surgeons achieve more accurate diagnosis and better pre-operative planning. Limitations to currently available stereoscopic displays which need to be addressed prior to widespread acceptance are: availability of hardware and software, loss of resolution, use of glasses, and image "ghosting". Journal publication, the traditional mode of information dissemination in orthopaedics, is also viewed as a hindrance to the acceptance of stereoscopy - it does not deliver the full impact of stereoscopy and "hands-on" demonstrations are needed.
Stephens, Trina; Mezei, Alexander; O'Hara, Nathan N; Potter, Jeffrey; Mugarura, Rodney; Blachut, Piotr A; O'Brien, Peter J; Beyeza, Tito; Slobogean, Gerard P
In low- and middle-income countries, the volume of traumatic injuries requiring orthopaedic intervention routinely exceeds the capacity of available surgical resources. The objective of this study was to identify predictors of surgical care for lower extremity fracture patients at a high-demand, resource-limited public hospital in Uganda. Skeletally mature patients admitted with the intention of definitive surgical treatment of an isolated tibia or femur fractures to the national referral hospital in Uganda were recruited to participate in this study. Demographic, socioeconomic, and clinical data were collected through participant interviews at the time of injury and 6 months post-injury. Social capital (use of social networks to gain access to surgery), financial leveraging, and ethnicity were also included as variables in this analysis. A probit estimation model was used to identify independent and interactive predictors of surgical treatment. Of the 64 patients included in the final analysis, the majority of participants were male (83%), with a mean age of 40.6, and were injured in a motor vehicle accident (77%). Due to resource constraints, only 58% of participants received surgical care. The use of social capital and femur fractures were identified as significant predictors of receiving surgical treatment, with social capital emerging as the strongest predictor of access to surgery (p < 0.05). Limited infrastructure, trained personnel, and surgical supplies rations access to surgical care. In this environment, participants with advantageous social connections were able to self-advocate for surgery where demand for these services greatly exceeded available resources.
Velikonja, T; Fisher, H L; Mason, O; Johnson, S
Schizotypy is a complex concept, commonly defined as a genetic vulnerability to schizophrenia that falls on a continuum between healthy variation and severe mental illness. There is a growing body of evidence supporting an association between childhood trauma and increased psychotic experiences and disorders. However, the evidence as to whether there is a similar association with schizotypy has yet to be systematically synthesized and assessed. We conducted a systematic search of published articles on the association between childhood trauma and schizotypy in four major databases. The search covered articles from 1806 to 1 March 2013 and resulted in 17,003 articles in total. Twenty-five original research studies met the eligibility criteria and were included in this review. All 25 studies supported the association between at least one type of trauma and schizotypy, with odds ratios (ORs) ranging between 2.01 and 4.15. There was evidence supporting the association for all types of trauma, with no differential effects. However, there was some variability in the quality of the studies, with most using cross-sectional designs. Individuals who reported adverse experiences in childhood scored significantly higher on positive and negative/disorganized schizotypy compared to those who did not report such experiences. All forms of childhood trauma and other stressful events (e.g. bullying) were found to be associated with schizotypy, with especially strong associations with positive schizotypy. However, because of the methodological limitations of several studies and a lack of further exploration of different possible mechanistic pathways underlying this association, more research is required.
Buijze, G A; Weening, A A; Poolman, R W; Bhandari, M; Ring, D
Using inaccurate quotations can propagate misleading information, which might affect the management of patients. The aim of this study was to determine the predictors of quotation inaccuracy in the peer-reviewed orthopaedic literature related to the scaphoid. We randomly selected 100 papers from ten orthopaedic journals. All references were retrieved in full text when available or otherwise excluded. Two observers independently rated all quotations from the selected papers by comparing the claims made by the authors with the data and expressed opinions of the reference source. A statistical analysis determined which article-related factors were predictors of quotation inaccuracy. The mean total inaccuracy rate of the 3840 verified quotes was 7.6%. There was no correlation between the rate of inaccuracy and the impact factor of the journal. Multivariable analysis identified the journal and the type of study (clinical, biomechanical, methodological, case report or review) as important predictors of the total quotation inaccuracy rate. We concluded that inaccurate quotations in the peer-reviewed orthopaedic literature related to the scaphoid were common and slightly more so for certain journals and certain study types. Authors, reviewers and editorial staff play an important role in reducing this inaccuracy.
Castillo, Renan C; Mackenzie, Ellen J; Bosse, Michael J
The ideal length of follow-up for orthopedic trauma research studies is unknown. This study compares 1- and 2-year complications, clinical recovery, and functional outcomes from a large prospective clinical study. Patients (n = 336) with limb threatening unilateral lower extremity injuries were followed at the 12, 24, and 84 months. Major outcomes observed were complications requiring hospital re-admission, fracture and wound healing, attainment of full weight bearing status, return to work, and self-reported functional outcome using the Sickness Impact Profile. The rate of newly observed complications beyond year 1 was small, ranging from 0 to <2%. In addition, 85% to 90% of the clinical recovery outcomes were attained by 1 year, and patients not achieving clinical recovery during the first year had significantly worse functional outcomes. Only 5% of patients returned to work between 1 year and 2 years. Although, a substantial number of patients achieved functional recovery between 1 year and 2 years, of the patients not achieving functional recovery at year 1, 85% of those who would go on to achieve functional recovery during the second year could be predicted using year 1 data. Although long-term follow-up provides a more complete picture of final outcomes and rate of recovery, follow-up beyond 1 year is difficult and expensive. In our study, it accounted for 20% of the total cost. The analysis of our data suggests that 1-year data were sufficient to address our major study hypotheses.
Langfitt, Maxwell K; Halvorson, Jason J; Scott, Aaron T; Smith, Beth P; Russell, Gregory B; Jinnah, Riyaz H; Miller, Anna N; Carroll, Eben A
To compare the efficacy of distal interlocking during intramedullary nailing using a freehand technique versus an electromagnetic field real-time system (EFRTS). A prospective, randomized controlled trial. Level I academic trauma center. Patients older than 18 years who sustained a femoral or tibial shaft fracture amenable to antegrade intramedullary nailing were prospectively enrolled between August 2010 and November 2011. Exclusion criteria included injuries requiring retrograde nailing and open wounds near the location of the distal interlocks (distal third of the femur, knee, or distal tibia). Each patient had 2 distal interlocking screws placed: one using the freehand method and the other using EFRTS. Techniques were compared on procedural time and number of interlocking screw misses. Two time points were measured: time 1 (time to find perfect circles/time from wand placement to drill initiation) and time 2 (drill initiation until completion of interlocking placement). Twenty-four tibia and 24 femur fractures were studied. EFRTS proved faster at times 1 and 2 (P < 0.0001 and P < 0.0002) and total time (P < 0.0001). This difference was larger for junior residents, though reached statistical significance for senior residents. Senior residents were faster with the freehand technique compared with junior residents (P < 0.004), but the 2 were similar using EFRTS (P = 0.41). The number of misses was higher with free hand compared with EFRTS (P = 0.02). These results suggest that EFRTS is faster than the traditional freehand technique and results in fewer screw misses. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Bulstrode, C; Gallagher, F A; Pilling, E L; Furniss, D; Proctor, R D
To assess whether a new form of teaching, the 'donut round', is as good at imparting factual knowledge as interactive lectures in both the short-term and the long-term. Randomised controlled trial. University of Oxford Medical School. 106 fifth year clinical medical students taught half of their A&E/trauma course by donut round and half by lecture. The results of multiple choice questions (MCQs) divided according to how the material was taught. Three MCQ papers were set: one at the end of a four-week course, one approximately 10 weeks later and a final exam approximately 17 months after the first. At the first MCQ, the average result for questions taught by donut round was 41.0 (out of 50) and for those taught by conventional lecture was 40.1. At 10 weeks these averages fell to 36.3 and 37.3 and at 17 months they were 38.7 and 38.1, respectively. None of these pairs were significantly different. Ratios were calculated for each candidate by dividing their donut round score by their lecture score. The average ratios for the first, second and third MCQ papers were: 1.029, 1.007 and 1.027, respectively, and were not significantly different. The individual ratios of all candidates in all three MCQs were plotted against their equivalent total mark. The calculated linear regression showed a statistically significant advantage of donut rounds over lectures in those candidates who scored a total mark less than 89 (n=260, p=0.02). Donut rounds are at least as good as lectures in imparting factual knowledge and may provide a selective advantage to weaker students.
Zou, Yuming; Li, Quan; Xu, Weidong
Objectives Orthopaedics-related diseases and conditions are a significant burden worldwide. In this study, we aimed to compare the quantity and quality of research output in the field of orthopaedics from Mainland China (MC), USA, UK, Japan and Germany. Setting The USA, UK, Japan, Germany and MC. Participants We selected orthopaedics journals from the subject category ‘orthopedics’ from the Science Citation Index Expanded (SCIE). Outcome measures The number of publications, the number of publications in the surveyed publication types, impact factor (IF) and citations from the corresponding country from 2005 to 2014 were collected for quantity and quality comparisons. Results A total of 128 895 articles were published worldwide in orthopaedics-related journals from 2005 to 2014. The USA contributed the largest proportion (31 190 (24.20%)), followed by the UK (6703 (5.20%)), Japan (5718 (4.41%)), Germany (4701 (3.66%)) and MC (3389 (2.63%)). Publications from MC represented the fewest, but this quantity is rapidly increasing. The quantity of annual publications from MC has exceeded that of Germany since 2012. The USA plays a predominant role in all kinds of publication types under investigation in the study, except in the category of meta-analysis. MC was in the last place for cumulative IFs, and the average IF actually decreased from the beginning of the study. For total and average citations, MC still lags behind the other countries in the study. Conclusions The USA has occupied the dominant place in orthopaedics-related research for the last 10 years. Although MC has made great progress in the number of published works in the field of orthopaedics over the last 10 years, the quality of these publishing efforts needs further improvement. PMID:27638493
Zou, Yuming; Li, Quan; Xu, Weidong
Orthopaedics-related diseases and conditions are a significant burden worldwide. In this study, we aimed to compare the quantity and quality of research output in the field of orthopaedics from Mainland China (MC), USA, UK, Japan and Germany. The USA, UK, Japan, Germany and MC. We selected orthopaedics journals from the subject category 'orthopedics' from the Science Citation Index Expanded (SCIE). The number of publications, the number of publications in the surveyed publication types, impact factor (IF) and citations from the corresponding country from 2005 to 2014 were collected for quantity and quality comparisons. A total of 128 895 articles were published worldwide in orthopaedics-related journals from 2005 to 2014. The USA contributed the largest proportion (31 190 (24.20%)), followed by the UK (6703 (5.20%)), Japan (5718 (4.41%)), Germany (4701 (3.66%)) and MC (3389 (2.63%)). Publications from MC represented the fewest, but this quantity is rapidly increasing. The quantity of annual publications from MC has exceeded that of Germany since 2012. The USA plays a predominant role in all kinds of publication types under investigation in the study, except in the category of meta-analysis. MC was in the last place for cumulative IFs, and the average IF actually decreased from the beginning of the study. For total and average citations, MC still lags behind the other countries in the study. The USA has occupied the dominant place in orthopaedics-related research for the last 10 years. Although MC has made great progress in the number of published works in the field of orthopaedics over the last 10 years, the quality of these publishing efforts needs further improvement. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Kaur, Randeep; Sud, Ambuj; Ghorpade, Nilesh; Gupta, Manu
Hyperglycemia is also seen amongst non-diabetics and can cause significant morbidity and mortality. SIH has been reported in literature and studied in relation to trauma and critically ill patients. However, literature specific to orthopaedics on this topic is very small. Further, management of hyperglycemia in such patients is still a matter of debate and no universal consensus exists regarding its management. Future studies are needed on this topic to provide appropriate management guidelines and optimal patient outcomes. PMID:25478381
Yilmaz, Mehmet; Akbulut, Sami; Kahraman, Aysegul; Yilmaz, Sezai
The aim of this study was to review the literature regarding the rupture of hydatid cysts into the abdominal cavity after trauma. We present both a new case of hydatid cyst rupture that occurred after blunt abdominal trauma and a literature review of studies published in the English language about hydatid cyst rupture after trauma; studies were accessed from PubMed, Google Scholar, EBSCO, EMBASE, and MEDLINE databases. We identified 22 articles published between 2000 and 2011 about hydatid cyst rupture after trauma. Of these, 5 articles were excluded because of insufficient data, duplication, or absence of intra-abdominal dissemination. The other 17 studies included 68 patients (38 males and 30 females) aged 8 to 76 years who had a ruptured hydatid cyst detected after trauma. The most common trauma included traffic accidents and falls. Despite optimal surgical and antihelmintic therapy, 7 patients developed recurrence. Complications included biliary fistula in 5 patients, incisional hernia in 2 patients, and gastrocutaneous fistula in 1 patient. Death occurred from intraoperative anaphylactic shock in 1 patient and gastrointestinal bleeding and pulmonary failure in 1 patient. Rupture of a hydatid cyst into the peritoneal cavity is rare and challenging for the surgeon. This condition is included in the differential diagnosis of the acute abdomen in endemic areas, especially in young patients. PMID:23113853
Mańka-Malara, Katarzyna; Gawlak, Dominika; Hovhannisyan, Anahit; Klikowska, Marta; Kostrzewa-Janicka, Jolanta
Endotracheal intubation is a procedure performed during general anaesthesia with the use of an endotracheal tube in order to maintain a patent airway. This routinely used procedure is connected with a risk of complications within the region of the masticatory system. Trauma of teeth, their surrounding structures and the soft tissue of the oral cavity is observed in app. 1.38 per 1000 procedures. The main causes of this damage are the surgical skills and experience of the surgeon, the anatomical conditions present and the mode of conducting the procedure. In order to reduce the risk of postoperative complications, patients with a high risk of sustaining an injury during endotracheal intubation should be equipped with elastic mouthguards, which reduces the possibility of damage. The scoring in a scale of endotracheal intubation difficulty should be used for qualification for the use of such mouthguards.
Petrone, Patrizio; Rodríguez Velandia, Wilson; Dziaková, Jana; Marini, Corrado P
Perineal injuries are uncommon, but not rare. They may present a wide variety of injury patterns which demand an accurate diagnostic assessment and treatment. Perineal injuries may occur as isolated injuries to the soft tissues or may be associated with pelvic organ, abdominal or even lower extremity injury. Hence the importance to know in depth not only the anatomy of the perineum and its organs, but also the implications of the patient's hemodynamic stability on the decision making process when treating these injuries using established trauma guidelines. The purpose of this review is to describe the current epidemiology and clinical presentation of perineal injuries in order to provide specific guidelines for the diagnosis and treatment of both stable and unstable patients. Copyright © 2016 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.
Yan, J.; MacDonald, A.; Baisi, L-P.; Evaniew, N.; Bhandari, M.
Objectives Despite the fact that research fraud and misconduct are under scrutiny in the field of orthopaedic research, little systematic work has been done to uncover and characterise the underlying reasons for academic retractions in this field. The purpose of this study was to determine the rate of retractions and identify the reasons for retracted publications in the orthopaedic literature. Methods Two reviewers independently searched MEDLINE, EMBASE, and the Cochrane Library (1995 to current) using MeSH keyword headings and the ‘retracted’ filter. We also searched an independent website that reports and archives retracted scientific publications (www.retractionwatch.com). Two reviewers independently extracted data including reason for retraction, study type, journal impact factor, and country of origin. Results One hundred and ten retracted studies were included for data extraction. The retracted studies were published in journals with impact factors ranging from 0.000 (discontinued journals) to 13.262. In the 20-year search window, only 25 papers were retracted in the first ten years, with the remaining 85 papers retracted in the most recent decade. The most common reasons for retraction were fraudulent data (29), plagiarism (25) and duplicate publication (20). Retracted articles have been cited up to 165 times (median 6; interquartile range 2 to 19). Conclusion The rate of retractions in the orthopaedic literature is increasing, with the majority of retractions attributed to academic misconduct and fraud. Orthopaedic retractions originate from numerous journals and countries, indicating that misconduct issues are widespread. The results of this study highlight the need to address academic integrity when training the next generation of orthopaedic investigators. Cite this article: J. Yan, A. MacDonald, L-P. Baisi, N. Evaniew, M. Bhandari, M. Ghert. Retractions in orthopaedic research: A systematic review. Bone Joint Res 2016;5:263–268. DOI: 10
Hart, Danielle; McNeil, Mary Ann; Hegarty, Cullen; Rush, Robert; Chipman, Jeffery; Clinton, Joseph; Reihsen, Troy; Sweet, Robert
There are many models currently used for teaching and assessing performance of trauma-related airway, breathing, and hemorrhage procedures. Although many programs use live animal (live tissue [LT]) models, there is a congressional effort to transition to the use of nonanimal- based methods (i.e., simulators, cadavers) for military trainees. We examined the existing literature and compared the efficacy, acceptability, and validity of available models with a focus on comparing LT models with synthetic systems. Literature and Internet searches were conducted to examine current models for seven core trauma procedures. We identified 185 simulator systems. Evidence on acceptability and validity of models was sparse. We found only one underpowered study comparing the performance of learners after training on LT versus simulator models for tube thoracostomy and cricothyrotomy. There is insufficient data-driven evidence to distinguish superior validity of LT or any other model for training or assessment of critical trauma procedures.
Ali, A M; Willett, K
Hospital admission rates for a number of conditions have been linked to variations in the weather. It is well established that trauma workload displays significant seasonal variation. A reliable predictive model might enable targeting of high-risk groups for intervention and planning of hospital staff levels. To our knowledge there have been no systematic reviews of the literature on the relationship between weather and trauma workload, and predictive models have thus far been informed by the results of single studies. We conducted a systematic review of bibliographic databases and reference lists up to June 2014 to identify primary research papers assessing the effect of specified weather conditions including temperature, rainfall, snow, fog, hail, humidity and wind speed on trauma workload, defined as admission to hospital, fracture or a Road Traffic Accident (RTA) resulting in a seriously injured casualty or fatality. 11,083 papers were found through electronic and reference search. 83 full papers were assessed for eligibility. 28 met inclusion criteria and were included in the final review; 6 of these related to the effect of the weather on trauma admissions, one to ambulance call out for trauma, 13 to fracture rate and 8 to RTAs. Increased temperature is positively correlated with trauma admissions. The rate of distal radius fractures is more sensitive to adverse weather than the rate of hip fractures. Paediatric trauma, both in respect of trauma admissions and fracture rate, is more sensitive to the weather than adult trauma. Adverse weather influences both RTA frequency and severity, but the nature of the relationship is dependent upon the timecourse of the weather event and the population studied. Important methodological differences between studies limit the value of the existing literature in building consensus for a generalisable predictive model. Weather conditions may have a substantial effect on trauma workload independent of the effects of seasonal
Abel, Rachel M.; Friedman, Howard A.
This article presents a review of literature focusing on mental health clinicians who have responded to war trauma in their work with children in Israeli schools. The review provides a brief introduction to the country's war history and inception of school psychological and counselling services. Within this framework, results of empirical…
Abel, Rachel M.; Friedman, Howard A.
This article presents a review of literature focusing on mental health clinicians who have responded to war trauma in their work with children in Israeli schools. The review provides a brief introduction to the country's war history and inception of school psychological and counselling services. Within this framework, results of empirical…
Park, W.M.; Hughes, S.P.F.
This book is an account of the principles of modern diagnostic imaging techniques and their applications in orthopedics. The aim is to show radiology as a dynamic subject. Orthopaedic Radiology is divided into two sections with the first part focusing on the principles of diagnostic imaging and interpretation and the second applying this information to practical clinical problems.
Wang, Zhao; Yang, Jin-Rui; Huang, Yu-Meng; Wang, Long; Liu, Long-Fei; Wei, Yong-Bao; Huang, Liang; Zhu, Quan; Zeng, Ming-Qiang; Tang, Zheng-Yan
Testicular rupture, one of the most common complications in blunt scrotal trauma, is the rupture of tunica albuginea and extrusion of seminiferous tubules. Testicular rupture is more inclined to young men, and injury mechanisms are associated with sports and motor accidents. After history taking and essential physical examination, scrotal ultrasound is the first-line auxiliary examination. MRI is also one of the vital complementary examinations to evaluate testicular rupture after blunt scrotal trauma. Surgical exploration and repair may be necessary when the diagnosis of testicular rupture is definite or suspicious. Postoperative follow-up is to monitor the relief of local symptoms and changes of testicular functions. This review sums up the literatures about testicular rupture after blunt scrotal trauma in recent 16 years and also refers some new advantages and perspectives on diagnosis and management of testicular rupture.
Poole, Daniele; Cortegiani, Andrea; Chieregato, Arturo; Russo, Emanuele; Pellegrini, Concetta; De Blasio, Elvio; Mengoli, Francesca; Volpi, Annalisa; Grossi, Silvia; Gianesello, Lara; Orzalesi, Vanni; Fossi, Francesca; Chiara, Osvaldo; Coniglio, Carlo; Gordini, Giovanni
Traumatic coagulopathy is thought to increase mortality and its treatment to reduce preventable deaths. However, there is still uncertainty in this field, and available literature results may have been overestimated. We searched the MEDLINE database using the PubMed platform. We formulated four queries investigating the prognostic weight of traumatic coagulopathy defined according to conventional laboratory testing, and the effectiveness in reducing mortality of three different treatments aimed at contrasting coagulopathy (high fresh frozen plasma/packed red blood cells ratios, fibrinogen, and tranexamic acid administration). Randomized controlled trials were selected along with observational studies that used a multivariable approach to adjust for confounding. Strict criteria were adopted for quality assessment based on a two-step approach. First, we rated quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Then, this rating was downgraded if other three criteria were not met: high reporting quality according to shared standards, absence of internal methodological and statistical issues not detailed by the GRADE system, and absence of external validity issues. With few exceptions, the GRADE rating, reporting and methodological quality of observational studies was "very low", with frequent external validity issues. The only two randomized trials retrieved were, instead, of high quality. Only weak evidence was found for a relation between coagulopathy and mortality. Very weak evidence was found supporting the use of fibrinogen administration to reduce mortality in trauma. On the other hand, we found high evidence that the use of 1:1 vs. 1:2 high fresh frozen plasma/packed red blood cells ratios failed to obtain a 12% mortality reduction. This does not exclude lower mortality rates, which have not been investigated. The use of tranexamic acid in trauma was supported by "high" quality evidence
Poole, Daniele; Cortegiani, Andrea; Chieregato, Arturo; Russo, Emanuele; Pellegrini, Concetta; De Blasio, Elvio; Mengoli, Francesca; Volpi, Annalisa; Grossi, Silvia; Gianesello, Lara; Orzalesi, Vanni; Fossi, Francesca; Chiara, Osvaldo; Coniglio, Carlo; Gordini, Giovanni
Background Traumatic coagulopathy is thought to increase mortality and its treatment to reduce preventable deaths. However, there is still uncertainty in this field, and available literature results may have been overestimated. Methods We searched the MEDLINE database using the PubMed platform. We formulated four queries investigating the prognostic weight of traumatic coagulopathy defined according to conventional laboratory testing, and the effectiveness in reducing mortality of three different treatments aimed at contrasting coagulopathy (high fresh frozen plasma/packed red blood cells ratios, fibrinogen, and tranexamic acid administration). Randomized controlled trials were selected along with observational studies that used a multivariable approach to adjust for confounding. Strict criteria were adopted for quality assessment based on a two-step approach. First, we rated quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Then, this rating was downgraded if other three criteria were not met: high reporting quality according to shared standards, absence of internal methodological and statistical issues not detailed by the GRADE system, and absence of external validity issues. Results With few exceptions, the GRADE rating, reporting and methodological quality of observational studies was “very low”, with frequent external validity issues. The only two randomized trials retrieved were, instead, of high quality. Only weak evidence was found for a relation between coagulopathy and mortality. Very weak evidence was found supporting the use of fibrinogen administration to reduce mortality in trauma. On the other hand, we found high evidence that the use of 1:1 vs. 1:2 high fresh frozen plasma/packed red blood cells ratios failed to obtain a 12% mortality reduction. This does not exclude lower mortality rates, which have not been investigated. The use of tranexamic acid in trauma was supported by
Trauma-informed care is an emerging value that is seen as fundamental to effective and contemporary mental health nursing practice. Trauma-informed care, like recovery, leaves mental health nurses struggling to translate these values into day-to-day nursing practice. Many are confused about what individual actions they can take to support these values. To date, the most clearly articulated policy to emerge from the trauma-informed care movement in Australia has been the agreement to reduce, and wherever possible, eliminate the use of seclusion and restraint. Confronted with the constant churn of admissions and readmissions of clients with challenging behaviours, and seemingly intractable mental illness, the elimination of seclusion and restraint is seen to be utopian by many mental health nurses in inpatient settings. Is trauma-informed care solely about eliminating seclusion and restraint, or are there other tangible practices nurses could utilize to effect better health outcomes for mental health clients, especially those with significant abuse histories? This article summarizes the findings from the literature from 2000-2011 in identifying those practices and clinical activities that have been implemented to effect trauma-informed care in inpatient mental health settings.
Arana-Garza, Sebastian; Juarez-Parra, Marco; Monterrubio-Rodríguez, Jeronimo; Cedillo-Alemán, Enrique; Orozco-Agüet, David; Zamudio-Vázquez, Zaire; Garza-Jasso, Tanya
Introduction Soft tissue injuries are relatively common after blunt neck trauma, because of its complex anatomy, many vital structures can be compromised. Isolated trauma to the thyroid is highly uncommon and there are few cases reported in the literature. Presentation of case A 19 year-old female patient with no known pathologies who sustained direct blunt trauma to the right frontal half of the neck after falling down from a stair case. She arrived at the ER with moderate neck swelling and pain. There were no visible hematomas and no respiratory compromise was noted. Contrast enhanced CT-scan showed rupture and hematoma of the right thyroid lobe; she underwent surgical exploration with hemi thyroidectomy and recovered uneventfully. Discussion Despite soft tissue injuries are relatively common after blunt neck trauma, isolated thyroid gland injury is extremely rare and is present in about 1–2% of the cases and in most of the cases there is an underlining pathology within the gland. Most patients arrived at the emergency room hemodynamically stable, presenting neck swelling, pain, respiratory distress, dysphagia and hoarseness. Diagnosis strategy should be focused to rule out respiratory or vascular compromise. Surgical exploration remains the most common treatment strategy. Conclusions Although the rarity of this condition, physicians should take in mind the possibility of thyroid injury after blunt neck trauma. Early detection and prompt treatment, can reduce life threatening complications. Management should be individualized to patient’s characteristics and surgeon’s experience. PMID:26001363
Tannvik, T D; Bakke, H K; Wisborg, T
Death from trauma is a significant and international problem. Outcome for patients suffering out-of-hospital cardiac arrests is significantly improved by early cardiopulmonary resuscitation. The usefulness of first aid given by laypeople in trauma is less well established. The aim of this study was to review the existing literature on first aid provided by laypeople to trauma victims and to establish how often first aid is provided, if it is performed correctly, and its impact on outcome. A systematic review was carried out, according to preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines, of all studies involving first aid provided by laypeople to trauma victims. Cochrane, Embase, Medline, Pubmed, and Google Scholar databases were systematically searched. Ten eligible articles were identified involving a total of 5836 victims. Eight studies were related to patient outcome, while two studies were simulation based. The proportion of patients who received first aid ranged from 10.7% to 65%. Incorrect first aid was given in up to 83.7% of cases. Airway handling and haemorrhage control were particular areas of concern. One study from Iraq investigated survival and reported a 5.8% reduction in mortality. Two retrospective autopsy-based studies estimated that correct first aid could have reduced mortality by 1.8-4.5%. There is limited evidence regarding first aid provided by laypeople to trauma victims. Due to great heterogeneity in the studies, firm conclusions can not be drawn. However, the results show a potential mortality reduction if first aid is administered to trauma victims. Further research is necessary to establish this.
Li, Quan-yue; Zhao, Dong-hai; Qu, Hai-yan; Zhou, Chuan-nong
BACKGROUND: Ascariasis is one of the most common human parasitic infections worldwide. In some rare cases, ascariasis may cause serious consequences even sudden death. This study was undertaken to review the life-threatening complications of ascariasis in trauma patients reported in the literature. DATA SOURCES: Relevant articles about ascariasis and trauma were searched from Pubmed, Google scholar, Scirus, and Wanfang databases. RESULTS: Twenty-four patients with ascariasis were collected from 21 articles searched. Most of these patients were from tropical and subtropical countries. Of the 24 patients, 12 were children. Their major complications occurred in the airway passage and digestive tract. There were 3 fatal cases in these patients. Twelve of the 24 patients described in 10 articles were reported in the last 10 years. CONCLUSIONS: Early diagnosis and prompt intervention are essential to minimize the high morbidity and mortality of these serious complications in trauma patients. Physicians should be aware of the possibility of Ascaris infection in a trauma patient from endemic area of ascariasis. History of Ascaris infection and routine examination of feces for Ascaris eggs may be helpful to make a correct diagnosis. PMID:25225578
Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery).
Magnone, Stefano; Coccolini, Federico; Manfredi, Roberto; Piazzalunga, Dario; Agazzi, Roberto; Arici, Claudio; Barozzi, Marco; Bellanova, Giovanni; Belluati, Alberto; Berlot, Giorgio; Biffl, Walter; Camagni, Stefania; Campanati, Luca; Castelli, Claudio Carlo; Catena, Fausto; Chiara, Osvaldo; Colaianni, Nicola; De Masi, Salvatore; Di Saverio, Salomone; Dodi, Giuseppe; Fabbri, Andrea; Faustinelli, Giovanni; Gambale, Giorgio; Capponi, Michela Giulii; Lotti, Marco; Marchesi, Gianmariano; Massè, Alessandro; Mastropietro, Tiziana; Nardi, Giuseppe; Niola, Raffaella; Nita, Gabriela Elisa; Pisano, Michele; Poiasina, Elia; Poletti, Eugenio; Rampoldi, Antonio; Ribaldi, Sergio; Rispoli, Gennaro; Rizzi, Luigi; Sonzogni, Valter; Tugnoli, Gregorio; Ansaloni, Luca
Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients
Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery)
Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients
This review aims to draw balanced conclusions about trauma and memory from the intensely polarized debate currently raging over "repressed" memories, or better, delayed memories (hereafter DM). Research suggests that: emotion impacts memory; psychogenic amnesia can be a reaction to unusual levels of trauma; memory is malleable and delayed memories are prone to errors; however, inaccuracies in traumatic memories are more likely to be in peripheral details than central details. Also reviewed are infantile amnesia, clinical surveys on DM, and two psychoanalytic perspectives on DM. Treatment recommendations are culled from the literature. In order that the debate over adult DM not divert attention from the reality of child abuse and its damage, child abuse issues begin and end the review.
Lim, E V; Aquino, N J
Orthopaedic surgery has progressed over the years because of innovative work of pioneering orthopaedic surgeons; new developments in internal fixation techniques and implants codeveloped with the orthopaedic manufacturing industry have improved treatment greatly. This article analyzes and reviews the relationship of orthopaedic surgeons to the orthopaedic implant industry, analyzing three broad categories of the relationship: (1) physicians receiving gifts from industry; (2) the orthopaedic industry's financial support of educational and research endeavors of academic trauma and other centers; and (3) the relationship of the industry with innovators in the field of orthopaedic surgery by retainer fees, royalties, and stock options from industry. The ethical relationship requires: (1) putting the patient's concerns first above vested interests; (2) an awareness of a potential for abuse; and (3) a level of awareness of the relationship and the ability to explain and inculcate this relationship in the teaching program of young residents to maintain the high standards that have been set.
Kaczynski, J; Wilczynska, M; Fligelstone, L; Hilton, J
The acute coagulopathy of trauma and shock is associated with significant mortality and, currently, there are no validated laboratory tests which allow for a rapid recognition and treatment of this condition. Therefore, early detection of any clot abnormality in trauma could improve the diagnosis of trauma-associated coagulopathy and subsequent interventions. Review of the literature. The standard laboratory tests, including prothrombin time and activated partial thromboplastin time, are unreliable and describe only an isolated fragment of the complex coagulation pathways. Additionally, thromboelastography and thromboelastometry operate in a non-linear regime which implies that clot formation is the product of both the clotting process and the effect of the measurement. The assessment of the clot microstructure using a scanning electron microscope has resulted in a subjective analysis of a clot structure, showing also poor correlation between the coagulation pathways and clot development. The fractal dimension provides information on the structure and quality of the initial clot, which subsequently acts as a template for how the mature clot will behave. However, these data require further verification in an in vivo setting. At present, the treatment of the coagulopathy is delivered by empirically administered massive transfusion protocols, which lack a specific target for replacement therapy. There is enough evidence to demonstrate that we urgently need a robust test, which would determine and quantify both the rate and the extent of coagulation abnormalities. This could help to tailor the treatment of coagulopathy according to the patient's needs.
Gamberini, Emiliano; Coccolini, Federico; Tamagnini, Beatrice; Martino, Costanza; Albarello, Vittorio; Benni, Marco; Bisulli, Marcello; Fabbri, Nicola; Hörer, Tal Martin; Ansaloni, Luca; Coniglio, Carlo; Barozzi, Marco; Agnoletti, Vanni
Resuscitative endovascular balloon occlusion of the aorta has been a hot topic in trauma resuscitation during these last years. The aims of this systematic review are to analyze when, how, and where this technique is performed and to evaluate preliminary results. The literature search was performed on online databases in December 2016, without time limits. Studies citing endovascular balloon occlusion of the aorta in trauma were retrieved for evaluation. Sixty-one articles met the inclusion criteria and were selected for the systematic review. Overall, they included 1355 treated with aortic endovascular balloon occlusion, and 883 (65%) patients died after the procedure. In most of the included cases, a shock state seemed to be present before the procedure. Time of death and inflation site was not described in the majority of included studies. Procedure-related and shock-related complications are described. Introducer sheath size and comorbidity seems to play the role of risk factors. Resuscitative endovascular balloon occlusion of the aorta is increasingly used in trauma victim resuscitation all over the world, to elevate blood pressure and limit fluid infusion, while other procedures aimed to stop the bleeding are performed. High mortality rate is probably due to the severity of the injuries. Time and place of balloon insertion, zone of balloon inflation, and inflation cutoff time are very heterogeneous.
Sbordone, L; Bortolaia, C
In the "Glossary of Periodontics Terms" written by the American Academy of Periodontology, the occlusal trauma is defined as "an injury to the attachment apparatus as a result of excessive occlusal forces". Nowadays, the effects of occlusal trauma on tooth support tissues, the onset and the progression of periodontal disease are still debated: many commonplaces have been disproved, but some doubts and not yet clear points remain, even owing to the difficult diagnosis of the presence and the real clinical impact of a traumatic occlusion. Then, ethical reasons prevent researchers from prospective clinical trials. At the beginning of the last century occlusal trauma has been supposed to be an etiologic factor of "alveolar pyorrhea", but several studies attending more strict scientific criteria failed to prove such correlation. On the basis of the bacterial genesis of periodontal disease, researchers started evaluating the possible effects of occlusal discrepancies on incidence, progression and treatment outcomes of periodontitis, but all the results underlined the more relevant role played by micro-organisms. The present review of the literature runs through this controversy again, analysing the most significant studies published.
Palan, J; Roberts, V; Bloch, B; Kulkarni, A; Bhowal, B; Dias, J
The use of journal clubs and, more recently, case-based discussions in order to stimulate debate among orthopaedic surgeons lies at the heart of orthopaedic training and education. A virtual learning environment can be used as a platform to host virtual journal clubs and case-based discussions. This has many advantages in the current climate of constrained time and diminishing trainee and consultant participation in such activities. The virtual environment model opens up participation and improves access to journal clubs and case-based discussions, provides reusable educational content, establishes an electronic record of participation for individuals, makes use of multimedia material (including clinical imaging and photographs) for discussion, and finally, allows participants to link case-based discussions with relevant papers in the journal club. The Leicester experience highlights the many advantages and some of the potential difficulties in setting up such a virtual system and provides useful guidance for those considering such a system in their own training programme. As a result of the virtual learning environment, trainee participation has increased and there is a trend for increased consultant input in the virtual journal club and case-based discussions. It is likely that the use of virtual environments will expand to encompass newer technological approaches to personal learning and professional development.
Huisman, Thierry A G M; Poretti, Andrea
Traumatic brain and spine injury (TBI/TSI) is a leading cause of death and lifelong disability in children. The biomechanical properties of the child's brain, skull, and spine, the size of the child, the age-specific activity pattern, and variance in trauma mechanisms result in a wide range of age-specific traumas and patterns of brain and spine injuries. A detailed knowledge about the various types of primary and secondary pediatric head and spine injuries is essential to better identify and understand pediatric TBI/TSI, which enhances sensitivity and specificity of diagnosis, will guide therapy, and may give important information about the prognosis. The purposes of this chapter are to: (1) discuss the unique epidemiology, mechanisms, and characteristics of TBI/TSI in children; (2) review the anatomic and functional imaging techniques that can be used to study common and rare pediatric TBI/TSI and their complications; (3) comprehensively review frequent primary and secondary brain injuries; and (4) to give a short overview of two special types of pediatric TBI/TSI: birth-related and nonaccidental injuries.
Stoica, B; Paun, S; Tanase, I; Negoi, I; Runcanu, A; Beuran, M
Despite the high frequency of thoracic injuries secondary to traffic related accidents, the blunt cardiac valve rupture is extremely rare. Case report and review of the literature using PubMed/MEDLINE and EMBASE databases. A 38 year old female patient, victim of car accident was admitted. On primary survey the patient was conscious, cooperative and hemodynamic and respiratory stable. On secondary survey was found a bilateral open leg fracture and a seat belt sign. Whole body Computed Tomography revealed minimal haemorrhagic contusion of the cortex, left hemopneumothorax and right pneumothorax, bilateral rib fractures, liver contusion, left femoral neck fracture and fracture to the lumbar spinal column. After bilateral pleurostomy, the patient becomes hemodynamically unstable, but with no signs of external bleeding. The transthoracic echocardiography revealed an acute severe tricuspid regurgitation with hepatic veins reflux. After orthopaedic surgeries, the tricuspid valve rupture was managed by replacing the valve with a bioprostheses. The hospital stay was 122 days. Only a high index of suspicion may reveal blunt cardiac lesions as a cause for hemodynamic instability in acute setting. Celsius.
Petzold, T; Haase, E; Niethard, F U; Schmitt, J
Due to current and prospective demographic developments, the provision of high-quality medical care is not guaranteed in Germany. The aim of this study is to analyze the utilization of medical service providers for diseases related to orthopedic/trauma surgery and deduce the corresponding number of medical service providers until 2050. Data provided by the Statistical Offices of the Federal Republic and the Federal States and the Scientific Institute of the AOK (2008-2012) were used to analyze the utilization behavior of four pre-determined orthopedic/trauma surgery disease groups (osteoarthritis, back pain, osteoporosis, trauma). Routine data of the current (2012) health care provision delivered by the compulsory health insurances (GKV) are the basis of the prognosis. Using population projections from the Federal Statistical Office, the health care demand until 2050 was predicted and using statistics from the German Medical Association, the number of required health care providers was determined. An increase in physician consultations until 2040 is expected for osteoarthritis (+ 21 %), osteoporosis (26 %), and trauma (+ 13 %). From 2040-2050 the health care utilization behavior of all examined diseases is expected to decrease. The increasing health care usage behavior until 2040 is associated with an increase in health care providers. Until 2030 a significant increase in the burden of orthopedic/trauma surgery diseases is expected. In 2050 the level of health care needs will be equivalent to that in 2030. Comprehensive needs assessment and planning are needed in order to create health care provision structures and processes that address potential changes in utilization behavior.
Strohmeier, Hannah; Scholte, Willem F
Working in humanitarian crisis situations is dangerous. National humanitarian staff in particular face the risk of primary and secondary trauma exposure which can lead to mental health problems. Despite this, research on the mental health of national staff is scarce, and a systematic analysis of up-to-date findings has not been undertaken yet. This article reviews the available literature on trauma-related mental health problems among national humanitarian staff. It focuses on the prevalence of selected mental health problems in relation to reference groups; sex and/or gender as predictive factors of mental health problems; and the influence of organization types on mental health problems. Three databases were systematically searched for relevant studies published in the English language in peer-reviewed journals. Fourteen articles matched the inclusion criteria. Findings suggest that national staff experience mental health problems and the prevalence of posttraumatic stress disorder, depression, and anxiety among this occupation group is mostly similar to or higher than among reference groups. Research on both substance use disorder and suicidal behavior among national staff is particularly scarce. The relation between sex and/or gender and mental health problems among national staff appears to be complex, and organizational staff support seems to be an important determinant for mental health. All findings call for increased attention from the humanitarian community and further research on the topic.
Strohmeier, Hannah; Scholte, Willem F.
Background Working in humanitarian crisis situations is dangerous. National humanitarian staff in particular face the risk of primary and secondary trauma exposure which can lead to mental health problems. Despite this, research on the mental health of national staff is scarce, and a systematic analysis of up-to-date findings has not been undertaken yet. Objective This article reviews the available literature on trauma-related mental health problems among national humanitarian staff. It focuses on the prevalence of selected mental health problems in relation to reference groups; sex and/or gender as predictive factors of mental health problems; and the influence of organization types on mental health problems. Method Three databases were systematically searched for relevant studies published in the English language in peer-reviewed journals. Results Fourteen articles matched the inclusion criteria. Findings suggest that national staff experience mental health problems and the prevalence of posttraumatic stress disorder, depression, and anxiety among this occupation group is mostly similar to or higher than among reference groups. Research on both substance use disorder and suicidal behavior among national staff is particularly scarce. The relation between sex and/or gender and mental health problems among national staff appears to be complex, and organizational staff support seems to be an important determinant for mental health. Conclusion All findings call for increased attention from the humanitarian community and further research on the topic. PMID:26589256
Wang, Hsiang-I; Yiang, Giou-Teng; Hsu, Chin-Wang; Wang, Jen-Chun; Lee, Chien-Hsing; Chen, Yu-Long
Thyroid storm, an endocrine emergency, remains a diagnostic and therapeutic challenge. It is recognized to develop as a result of several factors, including infection, surgery, acute illness, and rarely, trauma. Recognition of thyroid storm in a trauma patient is difficult because the emergency physician usually focuses on managing more obvious injuries. We present a case of trauma-related thyroid storm and review the previous literature on posttraumatic thyroid storm to delineate risk factors of the disease. The case occurred in a 32-year-old man after a motorcycle accident. Careful investigation of patient history and risk factors of trauma-related thyroid storms and utilization of the scoring system may facilitate early diagnosis. Traumatically induced thyroid storm usually responds to medical treatment developed for hyperthyroidism. Surgical intervention may be needed for patients who failed medical treatment or those with direct thyroid gland injuries. The outcome is usually fair under appropriate management. We present a case of trauma-related thyroid storm to illustrate the diagnostic and therapeutic approach with a summary of the previous literature. Emergency physicians should be aware of the clinical presentation and risk factors of patients with trauma-related thyroid storm to reduce the rate of misdiagnosis and prevent catastrophic outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.
New, Peter W.; Delafosse, Veronica
Objectives To illustrate the importance of multiple search terms and databases when searching publications on spinal cord damage not due to trauma. To develop comprehensive search filter for this subject, compare the results for 2000–2009 with the Medical Subject Headings (MeSH) and Emtree term ‘spinal cord diseases’ and determine changes in the number of articles over this period. Design Literature searches and search filter development. Setting Australia. Interventions Titles and abstracts searched in MEDLINE and EMBASE (2000–2009) for articles involving humans using search terms ‘non-traumatic spinal cord injury’ and ‘nontraumatic spinal cord injury’ (concise search). Develop comprehensive search filter for ‘spinal cord damage not due to trauma’ and compare the results with the MeSH term ‘spinal cord diseases.’ Outcome measures Annual publications (2000–2009) identified in MEDLINE and EMBASE literature searches. Results Concise search identified 35 articles published during 2000–2009. More publications were identified using the term ‘nontraumatic spinal cord injury’ (n = 20) than ‘non-traumatic spinal cord injury’ (n = 16). Publications increased for both terms ‘spinal cord diseases’ (2000 = 279; 2009 = 415) and ‘spinal cord damage not due to trauma’ identified by the comprehensive search filter (2000 = 1251; 2009 = 1921). Conclusions Concise searches using terms ‘non-traumatic spinal cord injury’ and ‘nontraumatic spinal cord injury’ fail to identify relevant articles unless combinations of terms and databases are used. These are inadequate search terms for a comprehensive search. Further research is needed to validate our comprehensive search filter. An international consensus process is required to establish an agreed term for ‘spinal cord damage not due to trauma.’ PMID:22333497
Haglin, Jack M; Eltorai, Adam E M; Gil, Joseph A; Marcaccio, Stephen E; Botero-Hincapie, Juliana; Daniels, Alan H
Patient-specific orthopaedic implants are emerging as a clinically promising treatment option for a growing number of conditions to better match an individual's anatomy. Patient-specific implant (PSI) technology aims to reduce overall procedural costs, minimize surgical time, and maximize patient outcomes by achieving better biomechanical implant fit. With this commercially-available technology, computed tomography or magnetic resonance images can be used in conjunction with specialized computer programs to create preoperative patient-specific surgical plans and to develop custom cutting guides from 3-D reconstructed images of patient anatomy. Surgeons can then place these temporary guides or "jigs" during the procedure, allowing them to better recreate the exact resections of the computer-generated surgical plan. Over the past decade, patient-specific implants have seen increased use in orthopaedics and they have been widely indicated in total knee arthroplasty, total hip arthroplasty, and corrective osteotomies. Patient-specific implants have also been explored for use in total shoulder arthroplasty and spinal surgery. Despite their increasing popularity, significant support for PSI use in orthopaedics has been lacking in the literature and it is currently uncertain whether the theoretical biomechanical advantages of patient-specific orthopaedic implants carry true advantages in surgical outcomes when compared to standard procedures. The purpose of this review was to assess the current status of patient-specific orthopaedic implants, to explore their future direction, and to summarize any comparative published studies that measure definitive surgical characteristics of patient-specific orthopaedic implant use such as patient outcomes, biomechanical implant alignment, surgical cost, patient blood loss, or patient recovery.
Hurst, K S; Phillips, R; Viant, W J; Mohsen, A M; Sherman, K P; Bielby, M
Trajectory planning and implementation forms a substantial part of current and future orthopaedic practice. This type of surgery is governed by a basic orthopaedic principle  which involves the placement of a surgical tool at a specific site within a region, via a trajectory which is planned from X-ray based 2D images and governed by 3D anatomical constraints. The accuracy and safety of procedures utilising the basic orthopaedic principle depends on the surgeon's judgement, experience, ability to integrate images, utilisation of intra-operative X-ray, knowledge of anatomical-biomechanical constraints and eye hand dexterity. The surgeon must remain as the responsible medical expert in charge of the overall system. At the same time the surgeon covets the accuracy offered by Computer Assisted Surgery including a manipulator. A summary of current inadequacies of manipulators indicates that the main drivers for future work are that accuracy is critical in close contact with the environment, safety concerns dictate manipulator geometry and technological limitations are many. In any effort to develop an optimal manipulator to guide surgical instruments and tools it is an obvious first step to review and categorise current manipulators. The aim of this paper is to review all aspects of manipulator design against the five main criteria of ergonomics; safety; accuracy; sterility and measurable benefits such as reduced operative time, reduced surgical trauma and improved clinical results.
Cahill, Thomas J; Gandhi, Rikesh; Allori, Alexander C; Marcus, Jeffrey R; Powers, David; Erdmann, Detlev; Hollenbeck, Scott T; Levinson, Howard
Craniomaxillofacial (CMF) fractures are typically treated with open reduction and internal fixation. Open reduction and internal fixation can be complicated by hardware exposure or infection. The literature often does not differentiate between these 2 entities; so for this study, we have considered all hardware exposures as hardware infections. Approximately 5% of adults with CMF trauma are thought to develop hardware infections. Management consists of either removing the hardware versus leaving it in situ. The optimal approach has not been investigated. Thus, a systematic review of the literature was undertaken and a resultant evidence-based approach to the treatment and management of CMF hardware infections was devised. A comprehensive search of journal articles was performed in parallel using MEDLINE, Web of Science, and ScienceDirect electronic databases. Keywords and phrases used were maxillofacial injuries; facial bones; wounds and injuries; fracture fixation, internal; wound infection; and infection. Our search yielded 529 articles. To focus on CMF fractures with hardware infections, the full text of English-language articles was reviewed to identify articles focusing on the evaluation and management of infected hardware in CMF trauma. Each article's reference list was manually reviewed and citation analysis performed to identify articles missed by the search strategy. There were 259 articles that met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There were 81 grade II articles included in the meta-analysis. Our meta-analysis revealed that 7503 patients were treated with hardware for CMF fractures in the 81 grade II articles. Hardware infection occurred in 510 (6.8%) of these patients. Of those infections, hardware removal occurred in 264 (51.8%) patients; hardware was left in place in 166 (32.6%) patients; and in 80 (15.6%) cases, there was no report as to hardware
Guryel, E; Acton, K; Patel, S
Clinical audit plays an important role in the drive to improve the quality of patient care and thus forms a cornerstone of clinical governance. Assurance that the quality of patient care has improved requires completion of the audit cycle. A considerable sum of money and time has been spent establishing audit activity in the UK. Failure to close the loop undermines the effectiveness of the audit process and wastes resources. We analysed the effectiveness of audit in trauma and orthopaedics at a local hospital by comparing audit projects completed over a 6-year period to criteria set out in the NHS National Audit and Governance report. Of the 25 audits performed since 1999, half were presented to the relevant parties and only 20% completed the audit cycle. Only two of these were audits against national standards and 28% were not based on any standards at all. Only a third of the audits led by junior doctors resulted in implementation of their action plan compared to 75% implementation for consultant-led and 67% for nurse-led audits. A remarkably large proportion of audits included in this analysis failed to meet accepted criteria for effective audit. Audits completed by junior doctors were found to be the least likely to complete the cycle. This may relate to the lack of continuity in modern medical training and little incentive to complete the cycle. Supervision by permanent medical staff, principally consultants, and involvement of the audit department may play the biggest role in improving implementation of change.
El Kafsi, J; Kraus, R; Guy, R
Seatbelt associated blunt trauma to the rectum is a rare but well recognised injury. The exact mechanism of hollow visceral injury in blunt trauma is unclear. Stress and shear waves generated by abdominal compression may in part account for injury to gas containing structures. A ‘seatbelt sign’ (linear ecchymosis across the abdomen in the distribution of the lap belt) should raise the suspicion of hollow visceral injuries and can be more severe with disruption of the abdominal wall musculature. Three consecutive cases of rectal injury following blunt abdominal trauma, requiring emergency laparotomy and resection, are described. Lumbar spine injury occurred in one case and in the other two cases, there was injury to the iliac wing of the pelvis; all three cases sustained significant abdominal wall contusion or muscle disruption. Abdominal wall reconstruction and closure posed a particular challenge, requiring a multidisciplinary approach. The literature on this topic is reviewed and potential mechanisms of injury are discussed. PMID:26741660
Ali, Sajid; Luni, Faraz Khan; Hashmi, Fayyaz; Taleb, Mohammed
Blunt trauma to chest cause injury to various cardiac structures. Isolated rupture of aortic valve without aortic dissection is rare complication of blunt chest trauma and can be caused by a tear or avulsion of the valve. We report a case of a 35-year-old male who presented with severe aortic insufficiency due to rupture of a non-infected congenital bicuspid aortic valve following non-penetrating chest trauma. The diagnosis was suggested by echocardiography and was confirmed by intra-operative and histological findings. The patient was successfully treated with surgical valve replacement with uneventful postoperative course and recovery. We describe patho-physiology, clinical manifestations, management and the literature review of traumatic rupture of bicuspid aortic valve. PMID:28164016
Kadish, H; Schunk, J; Woodward, G A
Blunt laryngotracheal trauma can be a life-threatening event. Two cases of isolated blunt laryngotracheal trauma in pediatric patients are presented. One case involves a 12-year-old mate who suffered isolated tracheal trauma from a fall. He developed respiratory distress and required a tracheostomy. Intraoperatively he was noted to have a thyroid cartilage fracture. The other case involves a 14-year-old female who was kicked in the neck by a horse. After unsuccessful intubation attempts that completed a tracheal transection, she required an emergency cricothyrotomy and a subsequent tracheostomy. The diagnosis, differential diagnosis, associated injuries, and treatment options for blunt laryngeal trauma are reviewed.
Joseph, Jacob R; Smith, Brandon W; Garton, Hugh J L
Blunt prenatal trauma is known to have consequences to the developing brain, and can result in subdural hematoma (SDH) or epidural hematoma (EDH). The authors present a case of blunt prenatal trauma resulting in a fetal SDH, intraparenchymal hematoma, and intraventricular hemorrhage, and perform a systematic review of the literature. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Relevant studies (up to April 2016) that reported on cases of fetal SDH or EDH after blunt prenatal trauma were identified from the PubMed database. The primary outcome was fetal mortality, and the secondary outcome was neurological outcome. Fourteen studies were included in the analysis, comprising a total of 14 patients including the present case. The average gestational age at discovery of hemorrhage was 30.1 weeks. Nine mothers were in a motor vehicle collision and 3 were assaulted; the mechanism of injury for 2 mothers was not defined. Twelve patients had SDH, 1 had EDH, and 1 had conflicting reports. Three patients had intrauterine fetal demise, and 3 died in the neonatal period after birth. Three patients had persistent neurological deficit, and 5 were neurologically intact. Fetal SDH or EDH after blunt trauma to the mother trauma is rare and is associated with mortality. However, a significant number of patients can have good neurological outcomes.
Wheeler, Janet; Davis, Deborah; Fry, Margaret; Brodie, Pat; Homer, Caroline S E
To undertake a systematic review of the literature to determine whether Asian ethnicity is an independent risk factor for severe perineal trauma in childbirth. Ovid Medline, CINAHL, and Cochrane databases published in English were used to identify appropriate research articles from 2000 to 2010, using relevant terms in a variety of combinations. All articles included in this systematic review were assessed using the Critical Appraisal Skills Programme (CASP) 'making sense of evidence' tools. Asian ethnicity does not appear to be a risk factor for severe perineal trauma for women living in Asia. In contrast, studies conducted in some Western countries have identified Asian ethnicity as a risk factor for severe perineal trauma. It is unknown why (in some situations) Asian women are more vulnerable to this birth complication. The lack of an international standard definition for the term Asian further undermines clarification of this issue. Nevertheless, there is an urgent need to explore why Asian women are reported to be significantly at risk for severe perineal trauma in some Western countries. Current research on this topic is confusing and conflicting. Further research is urgently required to explore why Asian women are at risk for severe perineal trauma in some birth settings. Copyright © 2011 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Kelley, S. P.; McMurray, D. H. M.; Hinsche, A. F.; Deacon, P.
INTRODUCTION: In 1993, the Major Trauma Working Group of Yorkshire proposed that hospitals should be accredited as Trauma Reception Hospitals with a policy for the response to the arrival of a trauma patient. These requirements include specific criteria for orthopaedics. METHODS: To evaluate if these criteria are being fulfilled, we carried out an audit comparing the response in the hospitals within the Yorkshire deanery to the arrival of major trauma. All consultant and middle-grade orthopaedic surgeons on call for trauma were contacted and questioned as to their ATLS provider status and involvement in the "trauma call". RESULTS: 16 hospitals were included of which 13 have a "trauma team". 191 surgeons (96% response) were included. 175 have completed an ATLS course. Of these, 72 (41%) had out-of-date qualifications. Only 9 (13%) were waiting to revalidate. Variation was seen in the frequency of accident and emergency department attendance by different grades of surgeon for major trauma. DISCUSSION: All hospitals have a response for major trauma although variations occur. The vast majority of orthopaedic surgeons in Yorkshire have been adequately trained in ATLS management (more so than any study has previously shown), particularly the middle grades, who are usually first to attend. The level of revalidation is low and reasons for this are discussed with recommendations for revalidation in the future. PMID:15720907
Kelley, S P; McMurray, D H M; Hinsche, A F; Deacon, P
In 1993, the Major Trauma Working Group of Yorkshire proposed that hospitals should be accredited as Trauma Reception Hospitals with a policy for the response to the arrival of a trauma patient. These requirements include specific criteria for orthopaedics. To evaluate if these criteria are being fulfilled, we carried out an audit comparing the response in the hospitals within the Yorkshire deanery to the arrival of major trauma. All consultant and middle-grade orthopaedic surgeons on call for trauma were contacted and questioned as to their ATLS provider status and involvement in the "trauma call". 16 hospitals were included of which 13 have a "trauma team". 191 surgeons (96% response) were included. 175 have completed an ATLS course. Of these, 72 (41%) had out-of-date qualifications. Only 9 (13%) were waiting to revalidate. Variation was seen in the frequency of accident and emergency department attendance by different grades of surgeon for major trauma. All hospitals have a response for major trauma although variations occur. The vast majority of orthopaedic surgeons in Yorkshire have been adequately trained in ATLS management (more so than any study has previously shown), particularly the middle grades, who are usually first to attend. The level of revalidation is low and reasons for this are discussed with recommendations for revalidation in the future.
Article aims to draw a balanced conclusion about trauma and memory from current information on repressed memories. Research suggests that (1) emotion impacts memory, (2) psychogenic amnesia can result from unusual levels of trauma, and (3) delayed memories are prone to errors. Inaccuracies in traumatic memories occur more often in peripheral…
Reif, Susan; Sullivan, Kristen; Murray, Kate; Barlow, Morgan L.; Whetten, Kathryn
Persons living with HIV (PLWH) report disproportionately high levels of exposure to traumatic events in childhood and adulthood. Traumatic experiences are associated with negative health and behavioral outcomes. Current research in this area seeks to further explicate the myriad health effects of trauma on PLWH and the pathways through which trauma operates. In this paper, we review articles published in English between January 2014 and June 2015 that examine traumatic experiences among PLWH, including intimate partner violence (IPV), domestic abuse, child abuse, and other forms of violence. A selection of studies examining trauma among PLWH and its associations with mental health, antiretroviral medication adherence, clinical outcomes, HIV disclosure, and sexual risk behaviors were included. Studies describing trauma coping strategies and interventions were also included. We conclude with recommendations for care of trauma-exposed PLWH and directions for future research. PMID:26419376
Two residents, wearing white coats with their names and "Department of Orthopaedics" conspicuously embroidered on them, boarded a hospital elevator crowded with physicians, employees, and visitors. In a clearly audible voice, one resident began a story: "You should have seen the patient I saw in my clinic the other day. She was beautiful. I should send her to see Dr. W. He would love to see her!" This comment drew the undivided attention of everyone in the elevator and cast a ghastly silence over the rest of the ride. In recent years, interest has expanded regarding professionalism and its importance in medicine and surgery. Orthopaedic surgery is no exception, as the topic has recently reached prominence in our literature and policies. It is unlikely that professionalism is a universal and innate characteristic of college students entering medical school, yet it becomes a necessary value in medical practice. Somewhere in the ongoing process of medical education, the issue must be addressed.
Barak, Michal; Bahouth, Hany; Leiser, Yoav; Abu El-Naaj, Imad
According to the Advanced Trauma Life Support recommendations for managing patients with life-threatening injuries, securing the airway is the first task of a primary caregiver. Airway management of patients with maxillofacial trauma is complex and crucial because it can dictate a patient's survival. Securing the airway of patients with maxillofacial trauma is often extremely difficult because the trauma involves the patient's airway and their breathing is compromised. In these patients, mask ventilation and endotracheal intubation are anticipated to be difficult. Additionally, some of these patients may not yet have been cleared of a cervical spine injury, and all are regarded as having a full stomach and having an increased risk of regurgitation and pulmonary aspiration. The requirements of the intended maxillofacial operation may often preclude the use of an oral intubation tube, and alternative methods for securing the airway should be considered before the start of the surgery. In order to improve the clinical outcome of patients with maxillofacial trauma, cooperation between maxillofacial surgeons, anesthesiologists, and trauma specialists is needed. In this review, we discuss the complexity and difficulties of securing the airway of patients with maxillofacial trauma and present our approach for airway management of such patients.
Barak, Michal; Bahouth, Hany; Leiser, Yoav; Abu El-Naaj, Imad
According to the Advanced Trauma Life Support recommendations for managing patients with life-threatening injuries, securing the airway is the first task of a primary caregiver. Airway management of patients with maxillofacial trauma is complex and crucial because it can dictate a patient's survival. Securing the airway of patients with maxillofacial trauma is often extremely difficult because the trauma involves the patient's airway and their breathing is compromised. In these patients, mask ventilation and endotracheal intubation are anticipated to be difficult. Additionally, some of these patients may not yet have been cleared of a cervical spine injury, and all are regarded as having a full stomach and having an increased risk of regurgitation and pulmonary aspiration. The requirements of the intended maxillofacial operation may often preclude the use of an oral intubation tube, and alternative methods for securing the airway should be considered before the start of the surgery. In order to improve the clinical outcome of patients with maxillofacial trauma, cooperation between maxillofacial surgeons, anesthesiologists, and trauma specialists is needed. In this review, we discuss the complexity and difficulties of securing the airway of patients with maxillofacial trauma and present our approach for airway management of such patients. PMID:26161411
Guryel, E; Acton, K; Patel, S
INTRODUCTION Clinical audit plays an important role in the drive to improve the quality of patient care and thus forms a cornerstone of clinical governance. Assurance that the quality of patient care has improved requires completion of the audit cycle. A considerable sum of money and time has been spent establishing audit activity in the UK. Failure to close the loop undermines the effectiveness of the audit process and wastes resources. PATIENTS AND METHODS We analysed the effectiveness of audit in trauma and orthopaedics at a local hospital by comparing audit projects completed over a 6-year period to criteria set out in the NHS National Audit and Governance report. RESULTS Of the 25 audits performed since 1999, half were presented to the relevant parties and only 20% completed the audit cycle. Only two of these were audits against national standards and 28% were not based on any standards at all. Only a third of the audits led by junior doctors resulted in implementation of their action plan compared to 75% implementation for consultant-led and 67% for nurse-led audits. CONCLUSIONS A remarkably large proportion of audits included in this analysis failed to meet accepted criteria for effective audit. Audits completed by junior doctors were found to be the least likely to complete the cycle. This may relate to the lack of continuity in modern medical training and little incentive to complete the cycle. Supervision by permanent medical staff, principally consultants, and involvement of the audit department may play the biggest role in improving implementation of change. PMID:18828963
Antunes, Antonio Azoubel; Santos, Thiago Santana; Carvalho de Melo, Allen Ulisses; Ribiero, Cyntia Ferreira; Goncalves, Suzane Rodrigues Jacinto; de Mello Rode, Sigmar
One of the most frequent consequences of trauma to the maxillofacial region is damage to teeth and supporting structures. Such damage can occur either in isolation or in conjunction with other fractures and soft tissue lacerations. In emergency situations, the harm caused to teeth could go unnoticed during the clinical examination, depending on the nature and complexity of the trauma and the primary care team's awareness of orofacial injuries. Fractured incisors often cause lacerations to the soft tissues at the time of trauma. During the diagnosis, particular care must be taken when such a fracture is associated with a soft tissue injury.
Kovelman, Inna; Vey, Eric; Schober, Justine
Homicides exclusively due to genital trauma have not been widely reported, and anorectal trauma in sexual assaults is uncommon. We describe a case of a 45-year-old white woman who sustained devastating homicidal colorectal trauma that served as a primary cause of death in the setting of rape. Our patient sustained a 15-cm laceration of the anterior rectal wall and ultimately died of peritonitis and sepsis. Death from rectal perforation and sepsis in the setting of sexual assault is rare and has only been documented in 3 other cases, 2 pediatric patients and 1 elderly debilitated patient. Other representative and unique methods of perforation are reviewed along with a brief discussion of the development of peritonitis after perforating colorectal trauma.
Chen, Antonia F; Wessel, Charles B; Rao, Nalini
Staphylococcus aureus is the most common organism responsible for orthopaedic surgical site infections (SSIs). Patients who are carriers for methicillin-sensitive S. aureus or methicillin-resistant S. aureus (MRSA) have a higher likelihood of having invasive S. aureus infections. Although some have advocated screening for S. aureus and decolonizing it is unclear whether these efforts reduce SSIs. The purposes of this study were to determine (1) whether S. aureus screening and decolonization reduce SSIs in orthopaedic patients and (2) if implementing this protocol is cost-effective. Studies for this systematic review were identified by searching PubMed, which includes MEDLINE (1946-present), EMBASE.com (1974-present), and the Cochrane Library's (John Wiley & Sons) Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTAD), and the NHS Economic Evaluation Database (NHSEED). Comprehensive literature searches were developed using EMTREE, MeSH, and keywords for each of the search concepts of decolonization, MRSA, and orthopedics/orthopedic surgery. Studies published before 1968 were excluded. We analyzed 19 studies examining the ability of the decolonization protocol to reduce SSIs and 10 studies detailing the cost-effectiveness of S. aureus screening and decolonization. All 19 studies showed a reduction in SSIs or wound complications by instituting a S. aureus screening and decolonization protocol in elective orthopaedic (total joints, spine, and sports) and trauma patients. The S. aureus screening and decolonization protocol also saved costs in orthopaedic patients when comparing the costs of screening and decolonization with the reduction of SSIs. Preoperative screening and decolonization of S. aureus in orthopaedic patients is a cost-effective means to reduce SSIs. Level IV, systematic review of Level I-IV studies. See the
Halis, Fikret; Amasyali, Akin Soner; Yucak, Aysel; Yildiz, Turan; Gokce, Ahmet
Abdominal trauma is responsible for most genitourinary injuries. The incidence of renal artery injury and intrathoracic kidney is quite low in patients who present with blunt trauma experiencing damage. There are four defined etiologies for intrathoracic kidney, which include real intrathoracic ectopic kidney, eventration of the diaphragm, congenital diaphragmatic herniation, and traumatic diaphragmatic rupture. The traumatic intrathoracic kidney is an extremely rare case. We presented intrathoracic kidney case after traumatic posterior diaphragmatic rupture. PMID:26881170
Karlakki, S.; Brem, M.; Giannini, S.; Khanduja, V.; Stannard, J.; Martin, R.
Objectives The period of post-operative treatment before surgical wounds are completely closed remains a key window, during which one can apply new technologies that can minimise complications. One such technology is the use of negative pressure wound therapy to manage and accelerate healing of the closed incisional wound (incisional NPWT). Methods We undertook a literature review of this emerging indication to identify evidence within orthopaedic surgery and other surgical disciplines. Literature that supports our current understanding of the mechanisms of action was also reviewed in detail. Results A total of 33 publications were identified, including nine clinical study reports from orthopaedic surgery; four from cardiothoracic surgery and 12 from studies in abdominal, plastic and vascular disciplines. Most papers (26 of 33) had been published within the past three years. Thus far two randomised controlled trials – one in orthopaedic and one in cardiothoracic surgery – show evidence of reduced incidence of wound healing complications after between three and five days of post-operative NPWT of two- and four-fold, respectively. Investigations show that reduction in haematoma and seroma, accelerated wound healing and increased clearance of oedema are significant mechanisms of action. Conclusions There is a rapidly emerging literature on the effect of NPWT on the closed incision. Initiated and confirmed first with a randomised controlled trial in orthopaedic trauma surgery, studies in abdominal, plastic and vascular surgery with high rates of complications have been reported recently. The evidence from single-use NPWT devices is accumulating. There are no large randomised studies yet in reconstructive joint replacement. Cite this article: Bone Joint Res 2013;2:276–84. PMID:24352756
Schmidt, Oliver I; Gahr, Ralf H; Gosse, Andreas; Heyde, Christoph E
Substantial inflammatory disturbances following major trauma have been found throughout the posttraumatic course of polytraumatized patients, which was confirmed in experimental models of trauma and in vitro settings. As a consequence, the principle of damage control surgery (DCS) has developed over the last two decades and has been successfully introduced in the treatment of severely injured patients. The aim of damage control surgery and orthopaedics (DCO) is to limit additional iatrogenic trauma in the vulnerable phase following major injury. Considering traumatic brain and acute lung injury, implants for quick stabilization like external fixators as well as decided surgical approaches with minimized potential for additional surgery-related impairment of the patient's immunologic state have been developed and used widely. It is obvious, that a similar approach should be undertaken in the case of spinal trauma in the polytraumatized patient. Yet, few data on damage control spine surgery are published to so far, controlled trials are missing and spinal injury is addressed only secondarily in the broadly used ATLS® polytrauma algorithm. This article reviews the literature on spine trauma assessment and treatment in the polytrauma setting, gives hints on how to assess the spine trauma patient regarding to the ATLS® protocol and recommendations on therapeutic strategies in spinal injury in the polytraumatized patient. PMID:19257904
Choi, Se Jin; Oh, Moon Young; Kim, Na Rae; Jung, Yoo Joong; Ro, Young Sun; Shin, Sang Do
The study aims to compare the trauma care systems in Asian countries. Asian countries were categorised into three groups; 'lower middle-income country', 'upper middle-income country' and 'high-income country'. The Medline/PubMed database was searched for articles published from January 2005 to December 2014 using relevant key words. Articles were excluded if they examined a specific injury mechanism, referred to a specific age group, and/or did not have full text available. We extracted information and variables on pre-hospital and hospital care factors, and regionalised system factors and compared them across countries. A total of 46 articles were identified from 13 countries, including Pakistan, India, Vietnam and Indonesia from lower middle-income countries; the Islamic Republic of Iran, Thailand, China, Malaysia from upper middle-income countries; and Saudi Arabia, the Republic of Korea, Japan, Hong Kong and Singapore from high-income countries. Trauma patients were transported via various methods. In six of the 13 countries, less than 20% of trauma patients were transported by ambulance. Pre-hospital trauma teams primarily comprised emergency medical technicians and paramedics, except in Thailand and China, where they included mainly physicians. In Iran, Pakistan and Vietnam, the proportion of patients who died before reaching hospital exceeded 50%. In only three of the 13 countries was it reported that trauma surgeons were available. In only five of the 13 countries was there a nationwide trauma registry. Trauma care systems were poorly developed and unorganised in most of the selected 13 Asian countries, with the exception of a few highly developed countries. © 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.
KARIBE, Hiroshi; KAMEYAMA, Motonobu; HAYASHI, Toshiaki; NARISAWA, Ayumi; TOMINAGA, Teiji
The number of cases with child abuse is increasing in Japan, and abusive head trauma (AHT) is a major cause of death in abused children. Child abuse has been recognized by the late 19th century, and widely accepted as battered child syndrome in the middle of the 20th century. As terms, there had been considerable mechanistic controversies between shaken-baby and -impact syndrome until the beginning of the 21st century. In recent years, AHT has been utilized as a less mechanistic term. Most of the characteristics of AHT in Japan have been similar to those in the United States as follows: infant is the most common victim, acute subdural hematoma (SDH) is the most common intracranial lesion, and retinal hemorrhage is often complicated. On the other hand, several characteristics have been different as follows: mother is the most common perpetrators, impact is a more common mechanism of trauma than shaking, and external trauma is more common reflecting the existence of impact. Since AHT as well as child abuse is a social pathological phenomenon influenced by victims, perpetrators, socioeconomic circumstances, and so on, various aspects of AHT as well as child abuse can be changed with times. Actually, a recent paper suggests such changes in infants with acute SDH due to AHT. In this review article, AHT, abusive infantile acute SDH in particular, are reviewed from the aspect of neurosurgical perspectives, including its mechanisms of trauma, biomechanics, clinical features, management, and prognosis, to update the trend in Japan. PMID:26960448
Singhvi, Hitesh Rajendra; Malik, Akshat; Chaturvedi, Pankaj
Chronic mucosal trauma resulting from sharp teeth, dentures, faulty restoration, or implants has frequently been associated with the development of oral cancer. The definitive evidence for the same is lacking. We undertook a search using the terms – dental trauma, mucosal trauma, oral cancer, squamous cell carcinoma, risk factor, potentially malignant lesion, dental factor, mechanical irritation, dental irritation, and cancer in the following electronic databases: MEDLINE, PubMed, ScienceDirect, Cochrane Database of Systematic Reviews, and Wiley InterScience. The search yielded 788 articles. Of these articles, only 22 articles described chronic mucosal trauma as risk factors for oral cancers and were considered in this review. The review shows that chronic mucosal irritation resulting from ill-fitting dentures may be considered a risk factor for the development of oral cancer, such cancers occur commonly over the lateral border of the tongue. However, no association has been proven between the duration of denture use and cancer formation. In patients without any addiction, such cancers occur more frequently in females. These cancers may present with an early nodal disease but their prognosis and outcomes have not been studied separately till now. PMID:28469336
van As, Arjan Bastiaan; Manganyi, Rodgers; Brooks, Andre
Thoracic injuries continue to be a leading cause of childhood trauma, despite the government's efforts to curb the scourge of this problem. Our review focuses on the incidence, etiology, and management of thoracic trauma in the pediatric population with reference to the recent experience at our institution in a developing country. For the literature review, the National Library of Medicine's PubMed database was searched for the following terms: "pediatric," "chest trauma," "hemothorax," "hemopneumothorax," "pneumothorax," "diaphragmatic," "esophageal," and "mediastinal injury." For the hospital data analysis, data of all 378 pediatric patients treated with thoracic injuries under the age of 13 years from 2008 to 2012 (a 5-year period), at the Red Cross War Memorial Children's Hospital, were retrospectively analyzed. The male to female ratio was 2.1:1 (255 males and 123 females). The mean age was 6.9 ± 2.3 years. Blunt chest trauma was responsible for chest injuries in 90.5%, while penetrating trauma caused 9.5% of the injuries. Road traffic crashes were the mean cause (48.9%) with pedestrian injuries in 72.4% and passenger injuries in 27.6%, respectively. Sports injuries were the cause in 4% and falls from a height in 22%. Most injuries occurred at home: inside one's own home (5%), outside one's own home (52%); inside someone else's home (44%); outside someone else's home (2%). Public space injuries occurred at schools or crèches in 77%, pavement or roads in 6%, and were not specified in 17%. Overall 74% presented with injuries of the thoracic cage; rib fractures occurred in 13%, chest wall contusions in 40%, and abrasions in 31%. Respiratory system injuries occurred in 22%; hemothoraces in 23%, pneumothoraces in 45%, and hemopneumothoraces in 29%. Cardiovascular injuries occurred in 16% of cases with vascular injuries in five patients (two firearms injuries and three motor vehicle crashes). Management was nonoperative in 79.4%, tube thoracotomy in 17.2%, and
Chen, Yan-xi; Zhang, Kun; Hao, Yi-ni; Hu, Yong-cheng
In the last 10 years, basic and clinical research in orthopaedics has developed rapidly. Understanding of orthopaedic disorders involves not only routine diagnosis, but also the pursuit of highly efficient and accurate three-dimensional imaging of the intra- and extra-medullary distribution, form and structure of orthopaedic disorders, thus allowing scientific evaluation of the indications for surgery, drawing up of the best surgical plan, minimization of operative trauma and the earliest possible restoration of limb function. Meanwhile, the most important type of basic research, which was previously biomechanical research, has gradually become computational biomechanics based on in vitro cadaver experiments. This review aims to summarize the research status and application prospects of digital technology in orthopaedics, including virtual reality technology, reverse engineering and rapid prototyping techniques, computational biomechanics, computer navigation technology and management of digitization of medical records.
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Oto, Brandon; Corey, Domenic John; Oswald, James; Sifford, Derek; Walsh, Brooks
The objectives were to review published reports of secondary neurologic deterioration in the early stages of care after blunt spinal trauma and describe its nature, context, and associated risk factors. The authors searched the MEDLINE, EMBASE, and CINAHL databases for English-language studies. Cases were included meeting the criteria age 16 years or older, nonpenetrating trauma, and experiencing neurologic deterioration during prehospital or emergency department (ED) care prior to definitive management (e.g., discharge, spinal clearance by computed tomography, admission to an inpatient service, or surgical intervention). Results were qualitatively analyzed for characteristics and themes. Forty-one qualifying cases were identified from 12 papers. In 30 cases, the new deficits were apparently spontaneous and were not detected until routine reassessment. In 12 cases the authors did attribute deterioration to temporally associated precipitants, seven of which were possibly iatrogenic; these included removal of a cervical collar, placement of a halo device, patient agitation, performance of flexion/extension films, "unintentional manipulation," falling in or near the ED, and forced collar application in patients with ankylosing spondylitis. Thirteen cases occurred during prehospital care, none of them sudden and movement-provoked, and all reported by a single study. Published reports of early secondary neurologic deterioration after blunt spinal trauma are exceptionally rare and generally poorly documented. High-risk features may include altered mental status and ankylosing spondylitis. It is unclear how often events are linked with spontaneous patient movement and whether such events are preventable. © 2015 by the Society for Academic Emergency Medicine.
Mehta, Samir; Smith, Jeffrey M
For those choosing a career in orthopaedic traumatology, several resources have been established by the Orthopaedic Trauma Association to facilitate progression from the years in training to the early years in practice. Young practitioners have access to educational programming, such as preparation for Part II of the Board Examination, web-based resources, such as on-line job postings, advocacy in health policy for the issues that will affect their ability to practice, and public relations efforts to increase their presence in the community. Ultimately, the resources set aside for the young practitioner by the Orthopaedic Trauma Association are intended to facilitate a sense of excellence, service, and community.
Yan, J; MacDonald, A; Baisi, L-P; Evaniew, N; Bhandari, M; Ghert, M
Despite the fact that research fraud and misconduct are under scrutiny in the field of orthopaedic research, little systematic work has been done to uncover and characterise the underlying reasons for academic retractions in this field. The purpose of this study was to determine the rate of retractions and identify the reasons for retracted publications in the orthopaedic literature. Two reviewers independently searched MEDLINE, EMBASE, and the Cochrane Library (1995 to current) using MeSH keyword headings and the 'retracted' filter. We also searched an independent website that reports and archives retracted scientific publications (www.retractionwatch.com). Two reviewers independently extracted data including reason for retraction, study type, journal impact factor, and country of origin. One hundred and ten retracted studies were included for data extraction. The retracted studies were published in journals with impact factors ranging from 0.000 (discontinued journals) to 13.262. In the 20-year search window, only 25 papers were retracted in the first ten years, with the remaining 85 papers retracted in the most recent decade. The most common reasons for retraction were fraudulent data (29), plagiarism (25) and duplicate publication (20). Retracted articles have been cited up to 165 times (median 6; interquartile range 2 to 19). The rate of retractions in the orthopaedic literature is increasing, with the majority of retractions attributed to academic misconduct and fraud. Orthopaedic retractions originate from numerous journals and countries, indicating that misconduct issues are widespread. The results of this study highlight the need to address academic integrity when training the next generation of orthopaedic investigators.Cite this article: J. Yan, A. MacDonald, L-P. Baisi, N. Evaniew, M. Bhandari, M. Ghert. Retractions in orthopaedic research: A systematic review. Bone Joint Res 2016;5:263-268. DOI: 10.1302/2046-3758.56.BJR-2016-0047. © 2016 Ghert et al.
Taylor, Anita; Staruchowicz, Lynda
informed by the experiences of the United States and United Kingdom and for the most part there exists a parallel between the international experience and the Australian experience of nurse practitioners.This review will focus on orthopaedic nurse practitioners in an international context. However the local context of the primary reviewer which informs this review is Australian. Australia has mirrored the trends around nurse practitioner practice found elsewhere. In the last 20 years (post implementation of the 1986 Australian nursing career structure), the debate around advanced nursing practice and nurse practitioners, in an Australian context, has developed. The inaugural 'legal & policy' nurse practitioner framework was developed in New South Wales (NSW) in 1998, with the first Australian nurse practitioner authorised to practise in NSW in 2000. It is posited that evaluation of emerging roles began to be seen in the research literature from 1990 onwards. In response to a need for creative workforce re-engineering and against a context of limited health resources, nurse practitioners in Australia over the last 20 years have emerged as an alternative model of health care delivery. For the last 10 years there has been a proliferation of influential 'reports' written by nurse researchers, generated to review the progress of Australia's nurse practitioners, commissioned by the health departments of respective state governments and other service planners to guide health workforce planning.In a national context the Australian Nursing & Midwifery Council (ANMC) as the peak national nursing body, defines a nurse practitioner as a Registered Nurse (RN) who is educated and authorised to practice autonomously and collaboratively in an advanced and extended clinical role. The ANMC Competency Standards for the Nurse Practitioner encompass three generic standards which are further defined by nine competencies. The competency standards provide a framework for practice and licensure of
Amirhamzeh, Daniel; Moor, Molly A; Baldwin, Keith; Hosalkar, Harish S
Earlier studies have indicated that across medical specialties, the overall publication rate of submitted manuscripts ranges from 36% to 66%. However, there have not been any recent studies conducted concerning the publication rates specifically for the Pediatric Orthopaedic Society of North America (POSNA). Consequently, the purpose of our study was to determine the overall publication rates of abstracts presented during the POSNA annual meetings, and whether there were differences in publication rates and time to publication according to type of presentation (podium vs. poster), journal, and orthopaedic subspecialty. A comprehensive literature search using PubMed and Google Scholar for all abstracts (including podiums, posters, and e-posters) presented at the 2002 to 2006 POSNA annual meetings was performed. Abstracts were classified according to presentation type: podium, poster, or e-posters, and were subsequently categorized into a specific orthopaedic subspecialty: basic science, hip, lower extremities, spine, trauma, and upper extremity. A total of 762 abstracts were presented at POSNA meetings between the years of 2002 and 2006. Of these 762 abstracts, 386 (50.7%) were published in peer-reviewed literature. There was no significant variation in the yearly publication percentage rate between 2002 and 2006 (P=0.63). However, overall time between presentation at POSNA and publication in a peer-reviewed journal varied significantly by year (P=0.002), with the average time to publication being 29 months in 2002, compared with 18.8 months in 2006. Time to publication also varied significantly by journal (P=0.025). For the combined years of 2002 to 2006, podiums were 1.47 times (95% confidence interval, 1.10-1.98) more likely to be published compared with posters (P=0.009). When abstracts were stratified by subspecialty (trauma, spine, hip, basic science, lower extremity, and upper extremity), there was no difference in publication rate between each group (P=0
Although the need for orthopaedic shoes is increasing, the number of skilled shoemakers has declined. This has led to the development of a CAD/CAM system to design and fabricate, orthopaedic footwear. The NASA-developed RIM database management system is the central repository for CUSTOMLAST's information storage. Several other modules also comprise the system. The project was initiated by Langley Research Center and Research Triangle Institute in cooperation with the Veterans Administration and the National Institute for Disability and Rehabilitation Research. Later development was done by North Carolina State University and the University of Missouri-Columbia. The software is licensed by both universities.
Sanders, James O; Otsuka, Norman Y; Martus, Jeffrey E
This past year has seen an increase in the quality of studies in pediatric orthopaedics, and the completion of BrAIST demonstrated that high-level studies of important questions can be addressed in pediatric orthopaedics. The current commitment of improving quality of care for children promises a healthy future for pediatric orthopaedics.
Tintle, Scott M; Levin, L Scott
Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.
Delaney, R A; Falvey, E; Kalimuthu, S; Molloy, M G; Fleming, P
The health benefits of exercise may be attenuated by sports and recreation related injury (SRI). Though the majority of SRI are mild and self-limiting, a significant number are serious and require orthopaedic intervention. The aims of this study were to assess the burden of these serious injuries on the orthopaedic inpatient service, and to investigate potential target areas for injury prevention. All 1,590 SRI seen in the ED over a 3-month period were analysed using the Patient Information Management System to determine which patients received inpatient orthopaedic care. The medical records of those 63 patients who required inpatient care under orthopaedics were reviewed and data collected on demographic features, history, operative procedure and theatre resources, and length of hospital stay. Data were analyzed using SPSS. SRI accounted for 12.3% of all ED presentations. The principal activities resulting in injury requiring orthopaedic care were soccer, hurling and informal play e.g. trampoline. Falls made up 37% of the overall mechanism of injury but 68% of the injuries severe enough to require operative management. Most operative procedures were performed as part of a routine day trauma list but 20% were performed out of hours. This group of injuries places a significant burden on a busy trauma service. Injury prevention measures such as public education regarding falls in sport may have a role in reducing this burden.
Teunis, Teun; Janssen, Stein; Guitton, Thierry G; Ring, David; Parisien, Robert
Much of the decision-making in orthopaedics rests on uncertain evidence. Uncertainty is therefore part of our normal daily practice, and yet physician uncertainty regarding treatment could diminish patients' health. It is not known if physician uncertainty is a function of the evidence alone or if other factors are involved. With added experience, uncertainty could be expected to diminish, but perhaps more influential are things like physician confidence, belief in the veracity of what is published, and even one's religious beliefs. In addition, it is plausible that the kind of practice a physician works in can affect the experience of uncertainty. Practicing physicians may not be immediately aware of these effects on how uncertainty is experienced in their clinical decision-making. We asked: (1) Does uncertainty and overconfidence bias decrease with years of practice? (2) What sociodemographic factors are independently associated with less recognition of uncertainty, in particular belief in God or other deity or deities, and how is atheism associated with recognition of uncertainty? (3) Do confidence bias (confidence that one's skill is greater than it actually is), degree of trust in the orthopaedic evidence, and degree of statistical sophistication correlate independently with recognition of uncertainty? We created a survey to establish an overall recognition of uncertainty score (four questions), trust in the orthopaedic evidence base (four questions), confidence bias (three questions), and statistical understanding (six questions). Seven hundred six members of the Science of Variation Group, a collaboration that aims to study variation in the definition and treatment of human illness, were approached to complete our survey. This group represents mainly orthopaedic surgeons specializing in trauma or hand and wrist surgery, practicing in Europe and North America, of whom the majority is involved in teaching. Approximately half of the group has more than 10 years
Goldsmith, Rachel E; Cheit, Ross E; Wood, Mary E
The current culture of traumatic stress studies includes research that identifies the ways in which stress and trauma impair learning and memory in both humans and animals. Yet it also contains health professionals who argue that individuals cannot forget traumatic events. Many accounts present differences among these positions as a legitimate debate despite the substantial forensic, survey, and neurological evidence that both demonstrates the capacity for people to exhibit impaired memory for trauma and highlights specific mechanisms. In a recent article, H. G. Pope, M. B. Poliakoff, M. P. Parker, M. Boynes, and J. I. Hudson (2007) hypothesized that if individuals could forget trauma, the phenomenon would appear in world literature prior to 1800. They conducted a contest to generate submissions of examples and determined that dissociative amnesia is a culture-bound syndrome. Their report fails to provide a thorough account of all submissions and the process through which they were all rejected, offers highly questionable literary analyses, and includes several misrepresentations of the state of the science regarding memory for trauma. This response addresses methodological problems with the contest, explores examples of forgetting trauma from literature written before 1800, examines social and historical aspects of the issue, and summarizes the extensive cognitive and neurological data that Pope et al. did not consider. The present article conceptualizes the premise of the contest and the authors' conclusion as symptomatic of a culture affected by biases that include the denial of trauma and its effects.
Röder, Christoph; El-Kerdi, A; Frigg, A; Kolling, C; Staub, L P; Bach, B; Müller, U
Following the tradition of the IDES European Hip Registry inaugurated by M. E. Müller in the 1960s, the Institute for Evaluative Research in Orthopaedic Surgery at the University of Bern started a new era of data collection using internet technology (www.memdoc.org). With support of the Swiss Orthopaedic Society, the pilot of the Swiss Orthopaedic Registry was conducted, and in cooperation with different academic and non-academic centers the practicability of integrating the various data collection instruments into the daily clinical workflow was evaluated. Three different sizes of hip and knee questionnaires were compiled, covering the individual demands of the participating hospitals whereby the smaller questionnaires always represent a subset of the next larger one. Different types of data collection instruments are available: the online interface, optical mark reader paper questionnaires, and barcode sheets. Precise implant tracking is implemented by scanning the implant barcodes directly in the operating theaters and linking them to the clinical data set via a central server. In addition, radiographic information can be linked with the clinical data set. The pilot clinics suggested enhancements to the user interface and additional features for data management. Also, recommendations were made to simplify content in some instances and diversify in others. With a new software release and adapted questionnaires the Swiss Orthopaedic Registry was officially launched in Summer 2005.
Lukins, Timothy R; Ferch, Richard; Balogh, Zsolt J; Hansen, Mitchell A
Management of the cervical spine following blunt trauma is commonplace. In 2013, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) published practice guidelines drawn from evidence dating to 2011. Since then, further publications have emerged that are reviewed, and a simple management algorithm produced to assist practitioners in Australian trauma centres. These publications attempt to shed light on two controversial scenarios, those being the management of symptomatic patients with negative computed tomography (CT) and management of the obtunded patient. The search strategy mirrored that of the AANS/CNS guidelines. A search of the National Library of Medicine (PubMed) database for manuscripts published between January 2011 and October 2014 was conducted. One reviewer extracted data from studies assessing the performance of various imaging modalities in identifying traumatic cervical spine injuries. In clinical scenarios where little evidence has emerged since the AANS/CNS guidelines, key manuscripts published prior to 2011 were identified from bibliographies. Awake, asymptomatic patients may be 'cleared' without further imaging. Awake, symptomatic patients without pathology on CT and without neurological deficit can safely be 'cleared' without magnetic resonance imaging. There is no longer a role for flexion-extension films. In the obtunded patient, findings remain conflicting. Several of these findings represent a departure from previous practices, including clearance of patients with non-neurological symptoms on the basis of CT and the exclusion of flexion-extension film in detecting injury. Management of the obtunded patient remains controversial. © 2015 Royal Australasian College of Surgeons.
Pigeon behavioural conditioning methods are similar to the processes that orthopaedic surgeons use to evaluate new surgical procedures. Alternatively, evidence-based orthopaedics is a tool for surgeons to evaluate procedures in a systematic, patient-centred way that is less instinctive than pigeon behaviour. The objective of this article is to describe evidence-based orthopaedics, and then propose changes to surgical culture with the aim of refining the interpretation of the current literature and improving the quality of future research. The proposals are 'institutional' changes rather than calls for increased funding and more randomised controlled trials.
Ogden, J. A.
Orthopaedic surgery must play a significant role in the development of sports medicine as a viable academic discipline. Potential areas in which orthopaedic surgery can specifically contribute to such an evolution are discussed. Particular areas include skeletal development, the role of athletics on skeletal growth and trauma response, the mechanics of specific sports and the predisposition of specific sports to certain injury patterns, the role of muscle physiology and muscle stimulation in rehabilitation, and differing responses of the male and female skeletal system. Each of these areas is discussed in detail. PMID:7445534
Gundtoft, Per Hviid; Brand, Eske; Klit, Jakob; Weisskirchner, Kristoffer Barfod
It is a general impression in the world of medicine that orthopaedic surgeons differ from doctors of other specialities in terms of intellect and self-confidence. The purpose of this study was to evaluate the self-confidence of orthopaedics. We asked doctors from 30 different specialities to fill out a questionnaire. In addition to this, the participating orthopaedics were asked to rate their self-perceived surgical skills. In all, 120 orthopaedics and 416 non-orthopaedic doctors completed the questionnaire. There was no difference in GSE scores between orthopaedics and other doctors (p = 0.58). 98% of young orthopaedics estimated that their surgical talent was average or above average when compared with their colleagues on the same level of education. 72% believed that they were "equally talented", "more talented", or "far more talented" than their colleagues on a higher level of education. 76% believed that when assisting a senior surgeon the patients would "sometimes" (60%), "often" (14%) or "always" (2%) be better off if they were the ones performing the operation. More orthopaedics than non-orthopaedics believed that their speciality was regarded as one of the least important specialities in the world of medicine (p = 0.001). Orthopaedic surgeons in general are not more self-confident than other doctors or the average population, but young orthopaedic surgeons have a very high level of confidence in their own operation skills. none. none.
Mabrey, Jay D; Reinig, Karl D; Cannon, W Dilworth
Virtual reality (VR) simulation has been a requirement for airline and military pilots for decades and is only now being integrated into surgical training programs. Thus far, orthopaedic training programs have been slow to adopt VR training. We therefore asked (1) how VR has worked for other surgical specialties; (2) what VR solutions are available for orthopaedics; and (3) should VR simulation become part of the orthopaedic curriculum? An informal literature review was performed, searching for orthopaedically-oriented VR surgical simulators and comparing this to the number of programs available for general surgery teaching programs. An in-depth review of a VR simulator for knee arthroscopy is also presented. WHERE ARE WE NOW?: The number of papers specific to orthopaedics and VR is limited. VR is used effectively in other specialties, especially general surgery. VR simulators are readily available for shoulder and knee arthroscopy but not as well incorporated into training curricula. WHERE DO WE NEED TO GO?: VR technology is available today for training programs. Integration of VR into the orthopaedic curriculum will save time in the OR, reduce operative errors, and improve the resident's overall educational experience. The public will expect their surgeons to train on these simulators. HOW DO WE GET THERE?: Orthopaedic training programs should take advantage of the commercially available VR simulators for orthopaedic procedures and incorporate them into their training curricula. This effort could be led by the American Academy of Orthopaedic Surgeons (AAOS) and the American Board of Orthopaedic Surgery (ABOS), two of the primary sponsors of a major study in the effectiveness of VR simulators for knee arthroscopy.
Tenenbaum, Shay; Weltsch, Daniel; Bariteau, Jason T; Givon, Adi; Peleg, Kobi; Thein, Ran
The use of electric bicycles (E-bike) has dramatically increased. E-bikes offer convenient, environmental-friendly, and less expensive alternative to other forms of transport. However, E-bikes provide a new public health challenge in terms of safety and injury prevention. This study is the first to specifically investigate the E-bike related orthopaedic injuries, based on a national trauma registry. Data from a National Trauma Registry were reviewed for patients hospitalized following E-bike related injuries. Between Jan 2014 to Dec 2015, a total of 549 patients were reviewed. Data were analyzed according to demography, type of orthopaedic injury, associated injuries and severity, injury mechanism and treatment in the operating room. A total of 360 (65%) patients sustained orthopaedic injuries, out of them 230 (63.8%) sustained limb/pelvis/spine fractures. Lower extremity fractures were more prevalent than upper extremity fractures (p<0.001). The tibia was the most fractured bone (19.2%). Patients over the age of 50 years were at the highest risk for spine (20. 5%, p=0.0001), pelvis (15.9%, p=0.0001) and femoral neck (15.9%, p=0.0172) fractures relative to other age groups. Approximately 42% of patients sustained associated injuries, with head/neck/face injuries being the most prevalent (30.3%). followed by chest (11.9%) and abdominal injury (13.3%). A collision between E-bike and a motorized vehicle was the mechanism of injury in 35% of cases. In this mechanism of injury, patients had 1.7 times the risk for associated injuries (p<0.0001) and the risk for major trauma (ISS score ≥16) was more than the double (p=0.03). One third of patients with orthopaedic injuries required treatment in the operating room. Treatment varied depending on the type of fracture. This study provides unique information on epidemiological characteristics of orthpaedic injuries caused be E-bikes, pertinent both to medical care providers, as well as to health policy-makers allocating
Erichsen, Daniel; Sellström, Håkan; Andersson, Henry
Although intussusception is a well-known cause of acute abdomen in the pediatric population, traumatic intussusception is exceedingly rare and has been reported previously only 6 times in a preadolescent child. We present a case of ileoileal intussusception in a previously healthy 6-year-old boy after blunt trauma to the abdomen and review the English language literature on the subject.
Williams, Geraint; Pattison, Giles; Mariathas, Chrishan; Lazar, Joanna; Rashied, Muhammad
No previous studies have attempted to measure parental satisfaction and service quality with regards to pediatric orthopaedic inpatient care. We performed a prospective observational study to identify areas of inpatient care which might be improved to increase overall parental satisfaction. We used the validated Swedish parent satisfaction questionnaire to generate data from 104 pediatric orthopaedic hospital inpatients between August 2009 and May 2010 (49 elective and 55 trauma pediatric orthopaedic admissions; median age range, 2 to 6 y). Questions focused on 8 domains of quality: information on illness, information on routines, accessibility, medical treatment, care processes, staff attitudes, parent participation, and staff work environment. Scores generated a percentage of the maximum achievable for that quality index. Data were analyzed using recognized statistical methods. Overall mean combined scores for the care indices were highest for parents' perception of "medical treatment" (95%) and "staff attitudes" (95%). The medical treatment index includes questions regarding staff member's skill and competence. Lowest scores corresponded to the index "information on routines" (86%). Information on routines applies to parental awareness of ward rounds, to whom questions should be directed and which doctors and nursing staff are responsible for their child's care. Lower scores in relation to this index were substantiated by comments from relatives requesting greater information provision. The information parents required was routinely provided suggesting that retention rather than lack of information is the main issue. Provision of information pamphlets tailored to common injuries or elective procedures might prove an effective method for improving parental satisfaction and overall care. Improving information provision and parental retention of this information is the strategy most likely to improve quality of service and parental satisfaction for pediatric
Schmidt, Oliver I; Gahr, Ralf H; Gosse, Andreas; Heyde, Christoph E
Substantial inflammatory disturbances following major trauma have been found throughout the posttraumatic course of polytraumatized patients, which was confirmed in experimental models of trauma and in vitro settings. As a consequence, the principle of damage control surgery (DCS) has developed over the last two decades and has been successfully introduced in the treatment of severely injured patients. The aim of damage control surgery and orthopaedics (DCO) is to limit additional iatrogenic trauma in the vulnerable phase following major injury. Considering traumatic brain and acute lung injury, implants for quick stabilization like external fixators as well as decided surgical approaches with minimized potential for additional surgery-related impairment of the patient's immunologic state have been developed and used widely. It is obvious, that a similar approach should be undertaken in the case of spinal trauma in the polytraumatized patient. Yet, few data on damage control spine surgery are published to so far, controlled trials are missing and spinal injury is addressed only secondarily in the broadly used ATLS(R) polytrauma algorithm. This article reviews the literature on spine trauma assessment and treatment in the polytrauma setting, gives hints on how to assess the spine trauma patient regarding to the ATLS(R) protocol and recommendations on therapeutic strategies in spinal injury in the polytraumatized patient.
Al-Hassani, Ammar; Jabbour, Gaby; ElLabib, Mohammad; Kanbar, Ahad; El-Menyar, Ayman; Al-Thani, Hassan
Introduction Delayed bile leak following blunt liver trauma is not common. Presentation of case We presented a case report and literature review of delayed bile leak in a young male patient who presented with grade IV blunt liver injury following a motor vehicle collision; he was a restrained driver who hit a fixed object. Physical examination was unremarkable except for revelaed tachycardia, right upper quadrant abdominal tenderness, and open left knee fracture. A diagnosis of grade IV multiple liver lacerations with large hemo-peritoneum was made and urgent exploratory laparotomy was performed. The patient developed a biloma collection post- operatively. He underwent endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct stenting. His recovery was uneventful, and he was discharged home after 1 month. Discussion This is a rare case with no intra or extra hepatic biliary radicle injury seen on magnetic resonance cholangiopancreatography (MRCP) and no evidence of leak by ERCP. A review of the literature to highlight the incidence of delayed bile leak revealed only few reported cases. Conclusion Our findings demonstrate the need for prompt diagnosis and treatment of delayed bile leak in blunt liver injuries. When these principles are followed, a successful outcome is possible. PMID:26279258
Friedlander, Eviatar; Pascual, Paula Martínez; Da Costa Belisario, Julia; Serafini, Daniel Poletti
Cricoarytenoid joint subluxation is rare condition. There are <200 cases reported in the English literature. The most frequent cause of this condition is a traumatic tracheal intubation which account for approximately 80 % of all cases. The most common symptoms are dysphonia and pain of the anterior region of the neck which appear after upper airway manipulation or cervical trauma. In this report we present a well-documented case of a 31 year old male that was referred to the outpatient clinic because of acute dysphonia and pain that appeared immediately after receiving a blow of a soccer ball. Diagnosis was suspected after patient reported the acute onset of symptoms after the traumatic event along with findings in flexible fiberoptic laryngoscopy and videostroboscopy. A CT scan of the larynx was done where the injury of the left cricoarytenoid joint was seen. The patient was informed of the condition and was given the option of surgical reduction or speech therapy. Speech therapy was done for 3 month and the patient was satisfied with the result, although the anatomical abnormality persisted. We reviewed the literature and we discuss the diagnosis process and possible treatment options.
Al-Hadithy, Nawfal; Gikas, Panagiotis D; Al-Nammari, Shafic Said
With the introduction of the European Working Time Directive, surgical trainees are facing limited training opportunities and doctors are required to maximise their training opportunities. Smartphone sales have been rapidly increasing over the last five years and can be used as a training tool for the orthopaedic trainee and surgeon. Common uses include applications (AO, eLogbook and PubMed), Ebooks, online Logbooks, Guidelines and surgical techniques. In addition, smartphones can be used to immediately complete work-based assessments, in the absence of computers, hopefully increasing completion rates and reliability. Some journals now provide podcasts and video tutorials which may be accessed on smartphones, which is useful for higher examinations. Smartphones can also be used in the clinical setting to take photographs of wounds. Smartphones are enjoying increased uptake and application in the workplace and we review their use for orthopaedic surgeons and trainees to allow them to make the most out of their training opportunities.
Pidgeon, Tyler S; Ramirez, Jose M; Schiller, Jonathan R
Spasticity is a common manifestation of many neurological conditions including multiple sclerosis, stroke, cerebral palsy, traumatic brain injury, and spinal cord injuries. Management of spasticity seeks to reduce its burden on patients and to limit secondary complications. Non-operative interventions including stretching/splinting, postural management, physical therapy/strengthening, anti-spasticity medications, and botulinum toxin injections may help patients with spasticity. Surgical management of these conditions, however, is often necessary to improve quality of life and prevent complications. Orthopaedic surgeons manage numerous sequelae of spasticity, including joint contractures, hip dislocations, scoliosis, and deformed extremities. When combined with the efforts of rehabilitation specialists, neurologists, and physical/occupational therapists, the orthopaedic management of spasticity can help patients maintain and regain function and independence as well as reduce the risk of long-tem complications.
Houlden, Henry; Charlton, Paul; Singh, Dishan
Neurology encompasses all aspects of medicine and surgery, but is closer to orthopaedic surgery than many other specialities. Both neurological deficits and bone disorders lead to locomotor system abnormalities, joint complications and limb problems. The main neurological conditions that require the attention of an orthopaedic surgeon are disorders that affect the lower motor neurones. The most common disorders in this group include neuromuscular disorders and traumatic peripheral nerve lesions. Upper motor neurone disorders such as cerebral palsy and stroke are also frequently seen and discussed, as are chronic conditions such as poliomyelitis. The management of these neurological problems is often coordinated in the neurology clinic, and this group, probably more than any other, requires a multidisciplinary team approach. PMID:17308288
Navarro, M; Michiardi, A; Castaño, O; Planell, J A
At present, strong requirements in orthopaedics are still to be met, both in bone and joint substitution and in the repair and regeneration of bone defects. In this framework, tremendous advances in the biomaterials field have been made in the last 50 years where materials intended for biomedical purposes have evolved through three different generations, namely first generation (bioinert materials), second generation (bioactive and biodegradable materials) and third generation (materials designed to stimulate specific responses at the molecular level). In this review, the evolution of different metals, ceramics and polymers most commonly used in orthopaedic applications is discussed, as well as the different approaches used to fulfil the challenges faced by this medical field.
Navarro, M; Michiardi, A; Castaño, O; Planell, J.A
At present, strong requirements in orthopaedics are still to be met, both in bone and joint substitution and in the repair and regeneration of bone defects. In this framework, tremendous advances in the biomaterials field have been made in the last 50 years where materials intended for biomedical purposes have evolved through three different generations, namely first generation (bioinert materials), second generation (bioactive and biodegradable materials) and third generation (materials designed to stimulate specific responses at the molecular level). In this review, the evolution of different metals, ceramics and polymers most commonly used in orthopaedic applications is discussed, as well as the different approaches used to fulfil the challenges faced by this medical field. PMID:18667387
Aluede, Edward E; Phillips, Jonathan; Bleyer, Jamie; Jergesen, Harry E; Coughlin, Richard
The developing world contains more than ¾ of the world's population, and has the largest burden of musculoskeletal disease. Published studies provide crucial information that can influence healthcare policies. Presumably much information regarding burden in the developing world would arise from authors from developing countries. However, the extent of participation of authors from the developing world in widely read orthopaedic journals is unclear. We surveyed four influential English-language orthopaedic journals to document the contributions of authors from developing countries. We surveyed Clinical Orthopaedics and Related Research, Journal of Orthopaedic Trauma, and the American and British volumes of The Journal of Bone and Joint Surgery, from May 2007 through May 2010. The country of origin of all authors was identified. We used the designations provided by the International Monetary Fund to define countries as either developed or developing. Two hundred sixty-five of 3964 publications (7%) included authors from developing countries. Ninety percent of these had authors from developing countries with industrialized and emerging-market economies. Publications from Sub-Saharan Africa accounted for only 0.4% of the 3964 articles reviewed and 5.6% of the 265 articles with developing world authorship. Countries with the least robust economies were least represented. Less than 1/3 of articles with authors from the developing world had coauthors from developed or other developing countries. Additional studies are needed to determine the reasons for the low representation noted and to establish strategies to increase the number of orthopaedic publications from parts of the world where the burden of musculoskeletal disease is the greatest.
The first nationwide orthopaedic registry was created in Sweden in 1975 to collect data on total knee arthroplasty (TKA). Since then, several countries have established registries, with varying degrees of success. Managing a registry requires time and money. Factors that contribute to successful registry management include the use of a single identifier for each patient to ensure full traceability of all procedures related to a given implant; a long-term funding source; a contemporary, rapid, Internet-based data collection method; and the collection of exhaustive data, at least for innovative implants. The effects of registries on practice patterns should be evaluated. The high cost of registries raises issues of independence and content ownership. Scandinavian countries have been maintaining orthopaedic registries for nearly four decades (since 1975). The first English-language orthopaedic registry was not created until 1998 (in New Zealand), and both the US and many European countries are still struggling to establish orthopaedic registries. To date, there are 11 registered nationwide registries on total knee and total hip replacement. The data they contain are often consistent, although contradictions occur in some cases due to major variations in cultural and market factors. The future of registries will depend on the willingness of health authorities and healthcare professionals to support the creation and maintenance of these tools. Surgeons feel that registries should serve merely to compare implants. Health authorities, in contrast, have a strong interest in practice patterns and healthcare institution performances. Striking a balance between these objectives should allow advances in registry development in the near future.
Patton, Chad M; Powell, Amy P; Patel, Alpesh A
Vitamin D is an important component in musculoskeletal development, maintenance, and function. Adequate levels of vitamin D correlate with greater bone mineral density, lower rates of osteoporotic fractures, and improved neuromuscular function. Debate exists about both adequate levels required and intake requirements needed to prevent deficiency of vitamin D. Epidemiologic data have identified an increasing number of orthopaedic patients at risk for vitamin D deficiency, with potentially widespread consequences for bone healing, risk of fracture, and neuromuscular function.
Kocher, Mininder S
Value has become the buzzword of contemporaneous health care reform. Value is defined as outcomes relative to costs. Orthopaedic surgery has come under increasing scrutiny due to high procedural costs. However, orthopaedic surgery may actually be a great value given the benefits of treatment. The American Academy of Orthopaedic Surgeons (AAOS) Value Project team was tasked to develop a model for assessing the benefits of orthopaedic surgery including indirect costs related to productivity and health-related quality of life. This model was applied to 5 orthopaedic conditions demonstrating robust societal and economic value. In all cost-effectiveness models, younger patients demonstrated greater cost-effectiveness given increased lifespan and productivity. This has tremendous implications within the field of pediatric orthopedic surgery. Pediatric orthopaedics may be the best value in medicine!
Maschi, Tina; Dennis, Kelly Sullivan; Gibson, Sandy; MacMillan, Thalia; Sternberg, Susan; Hom, Maryann
The purpose of this article was to review the empirical literature that investigated trauma and stress among older adults in the criminal justice system. Nineteen journal articles published between 1988 and 2010 were identified and extracted via research databases and included mixed age samples of adjudicated older and younger adults (n = 11) or older adult only samples (n = 8). Findings revealed past and current trauma and stress, consequences and/or correlates, and internal and external coping resources among aging offenders. The implications and future directions for gerontological social work, research, and policy with older adults in the criminal justice system are advanced.
Buckwalter, Joseph A
Over the last 50 years, the commitment of orthopaedic surgeons to basic and clinical research and evaluation of treatment outcomes has made possible remarkable improvements in the care of people with injuries and diseases of the limbs and spine. A group of Oregon orthopaedic surgeons has had an important role in these advances, especially in the orthopaedic specialties of sports medicine and hip reconstruction. Since Don Slocum (Iowa Orthopaedic Resident, 1934-1937), started practice in Eugene, Oregon, in 1939, three orthopaedic surgeons, Denny Collis, Craig Mohler and Paul Watson, who received their orthopaedic residency education at the University of Iowa, and three orthopaedic surgeons, Stan James, Tom Wuest and Dan Fitzpatrick, who received their undergraduate, medical school and orthopaedic residency education at the University of Iowa, have joined the group Dr. Slocum founded. These individuals, and their partners, established and have maintained a successful growing practice that serves the people of the Willamette valley, but in addition, they have made important contributions to the advancement of orthopaedics.
Buckwalter, Joseph A
Over the last 50 years, the commitment of orthopaedic surgeons to basic and clinical research and evaluation of treatment outcomes has made possible remarkable improvements in the care of people with injuries and diseases of the limbs and spine. A group of Oregon orthopaedic surgeons has had an important role in these advances, especially in the orthopaedic specialties of sports medicine and hip reconstruction. Since Don Slocum (Iowa Orthopaedic Resident, 1934-1937), started practice in Eugene, Oregon, in 1939, three orthopaedic surgeons, Denny Collis, Craig Mohler and Paul Watson, who received their orthopaedic residency education at the University of Iowa, and three orthopaedic surgeons, Stan James, Tom Wuest and Dan Fitzpatrick, who received their undergraduate, medical school and orthopaedic residency education at the University of Iowa, have joined the group Dr. Slocum founded. These individuals, and their partners, established and have maintained a successful growing practice that serves the people of the Willamette valley, but in addition, they have made important contributions to the advancement of orthopaedics. PMID:14575262
Cahill, Patrick J; Refakis, Christian; Storey, Eileen; Warner, William C
A concussion is a relatively common sports-related injury that affects athletes of all ages. Although orthopaedic surgeons are not expected to replace sports medicine physicians and neurologists with regard to the management of concussions, orthopaedic surgeons, particularly those who are fellowship-trained in sports medicine, must have a current knowledge base of what a concussion is, how a concussion is diagnosed, and how a concussion should be managed. Orthopaedic surgeons should understand the pathophysiology, assessment, and management of concussion so that they have a basic comprehension of this injury, which is at the forefront of the academic literature and North American media. This understanding will prepare orthopaedic surgeons to work in concert with and assist sports medicine physicians, athletic trainers, and physical therapists in providing comprehensive care for athletes with a concussion.
Large intersubject variability in the susceptibility to noise-induced hearing loss (NIHL) is known to occur in both humans and animals. It has been suggested that the olivocochlear system (OCS) plays a significant role in protecting the cochlea from exposure to high levels of noise. A mini literature review about the scientific evidence from animal and human studies about the association between the function of the OCS and susceptibility to NIHL was carried out. Animal data consistently show that de-efferented ears exhibit larger temporary threshold shift (TTS) and permanent threshold shift (PTS) than efferented ears. Data from human studies do not consistently show a correlation between the strength of the OCS function and amount of TTS. Further research on human subjects is required to determine how the OCS function could be used to predict susceptibility to NIHL in individual subjects. PMID:26157366
McNerney, Patrick; Kiproff, Paul
Profunda femoris artery (PFA) pseudoaneurysm after blunt trauma without associated femur fracture is a rare occurrence. Most of the reported cases of PFA pseudoaneurysm in the English literature developed after penetrating trauma, surgical procedures, and femur fractures. We present two such cases following blunt trauma and without any associated long bone injury. After initial imaging failed to show any long bone fracture, CT angiography confirmed pseudoaneurysm of the branch of the PFA. Both patients were then treated with emergent coil embolization of the bleeding vessel. Pseudoaneurysms typically present late and signs of persistent hip pain, thigh swelling, presence of a pulsatile mass, and even unexplained anemia all may suggest the diagnosis. Recognition of PFA pseudoaneurysm requires high index of suspicion and is often difficult to diagnose clinically because of its location. PMID:28246563
Kapur, Richard A
Acoustic emission (AE) is the phenomenon of sonic and ultrasonic wave generation by materials as they undergo deformation and fracture processes. AE monitoring is widely used throughout civil and mechanical engineering as a highly sensitive and non-destructive technique for structural health monitoring. Advances in computational power and digital data storage have generated much further interest in the possible applications of AE technology. Of particular interest has been its application within the field of Orthopaedic surgery. This paper examines the current literature surrounding the use of AE technology within Orthopaedics and provides a comprehensive overview of its current applications within Orthopaedic surgery. The use of AE technology in Orthopaedics is wide ranging and is discussed under the themes of: the study of the biomechanical properties of bone and fracture mechanics, research into failure mechanisms associated with cemented implants, prosthetic design, diagnostic value of AE and clinical application. AE technology is of great benefit as an Orthopaedic research tool where AE counts can be used to provide a surrogate marker for damage accumulation and flaws can be monitored as they develop. More recently there has been increased interest in the possible clinical applications of AE technology and an appreciation of the potential benefits for the diagnosis and treatment of Orthopaedic pathology. Despite the challenges involved when adopting AE techniques in vivo the potential of AE technology within Orthopaedics is significant. Already widely used in the research setting, clinical application has shown enormous potential and is a rapidly expanding area of contemporary research. This analysis will review and summarise the current literature relating to the use of AE technology within Orthopaedic surgery. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.
Introduction Crush asphyxia is different from positional asphyxia, as respiratory compromise in the latter is caused by splinting of the chest and/or diaphragm, thus preventing normal chest expansion. There are only a few cases or small case series of crush asphyxia in the literature, reporting usually poor outcomes. Case presentation We present the case of a 44-year-old Caucasian man who developed traumatic asphyxia with severe thoracic injury and mild brain edema after being crushed under heavy auto vehicle mechanical parts. He remained unconscious for an unknown time. The treatment included oropharyngeal intubation and mechanical ventilation, bilateral chest tube thoracostomies, treatment of brain edema and other supportive measures. Our patient’s outcome was good. Traumatic asphyxia is generally under-reported and most authors apply supportive measures, while the final outcome seems to be dependent on the length of time of the chest compression and on the associated injuries. Conclusion Treatment for traumatic asphyxia is mainly supportive with special attention to the re-establishment of adequate oxygenation and perfusion; treatment of the concomitant injuries might also affect the final outcome. PMID:22935547
Kenney, Kristin S; Fanciullo, Lisa M
Although air bags are placed in automobiles to act as safety devices, they have been shown to carry a risk of injury themselves. Ocular injury, in particular, can often be a direct consequence of air bag deployment. A case of ocular air bag injury is presented. A discussion and review of the current literature on this issue follows. A 63-year-old man was transferred to our clinic after sustaining injuries related to a motor vehicle accident, during which the automobile's air bag was deployed. Initial examination revealed many signs of blunt ocular trauma of the O.D., including iridodialysis, dislocated lens with traumatic cataract, and traumatic/inflammatory glaucoma. Initial B-scan showed an attached retina O.D. One month later, the patient underwent an attempted pars plana vitrectomy with lensectomy, iris repair, and insertion of an anterior chamber intraocular lens. Complications arose during the procedure, and a total retinal detachment developed. Resultant acuity is no light perception O.D. Although ocular morbidity can be a direct consequence of air bag deployment, most eye injuries are minimal, and seem to be outweighed by the benefits of air bags. Drivers, as well as passengers, can minimize associated injuries by adhering to specific safety guidelines. This, as well as continual modification and improvement in air bag design, will maximize the safety of air bags and decrease the incidence of vision-threatening ocular injury caused by air bag deployment.
Franko, Orrin I
The use of smartphones and their associated applications (apps) provides new opportunities for physicians, and specifically orthopaedic surgeons, to integrate technology into clinical practice. The purpose of this study was twofold: to review all apps specifically created for orthopaedic surgeons and to survey orthopaedic residents and surgeons in the United States to characterize the need for novel apps. The five most popular smartphone app stores were searched for orthopaedic-related apps: Blackberry, iPhone, Android, Palm, and Windows. An Internet survey was sent to ACGME-accredited orthopaedic surgery departments to assess the level of smartphone use, app use, and desire for orthopaedic-related apps. The database search revealed that iPhone and Android platforms had apps specifically created for orthopaedic surgery with a total of 61 and 13 apps, respectively. Among the apps reviewed, only one had greater than 100 reviews (mean, 27), and the majority of apps had very few reviews, including AAOS Now and AO Surgery Reference, apps published by the American Academy of Orthopaedic Surgeons and AO Foundation, respectively. The national survey revealed that 84% of respondents (n = 476) have a smartphone, the majority (55%) have an iPhone, and that 53% of people with smartphones already use apps in clinical practice. Ninety-six percent of respondents who use apps reported they would like more orthopaedic apps and would pay an average of nearly $30 for useful apps. The four most requested categories of apps were textbook/reference, techniques/guides, OITE/board review, and billing/coding. The use of smartphones and apps is prevalent among orthopaedic care providers in academic centers. However, few highly ranked apps specifically related to orthopaedic surgery are available, and the types of apps available do not appear to be the categories most desired by residents and surgeons.
King, J B
Orthopaedic surgeons have long had an association with sport, although it is arguable whether Galen who was the first sports medicine doctor, appointed to the Pergamum Gladiators in 157 AD was a surgeon by todays definition. This surgical role is now out of proportion to the more global aspects of sports medicine as reflected in the rest of this publication, but accurately related to the consequences of injury to the elite performer, where a minor injury may have a major consequence. As the title makes clear this chapter is a series of cameos some describing aspects of the management of common injuries and others indicating new developments.
Romanova, K; Vassileva, J; Alyakov, M
The aim of the present study was to assess the radiation dose to the eye lens of orthopaedic surgeons during various orthopaedic procedures and to make efforts to ensure that radiation protection is optimised. The study was performed for Fractura femoris and Fractura cruris procedures performed in orthopaedic operating theatres, as well as for fractures of wrist, ankle and hand/shoulder performed in the emergency trauma room. The highest mean value of the eye lens dose of 47.2 μSv and higher mean fluoroscopy time of 3 min, as well as the corresponding highest maximum values of 77.1 μSv and 5.0 min were observed for the Fractura femoris procedure performed with the Biplanar 500e fluoroscopy systems. At a normal workload, the estimated mean annual dose values do not exceed the annual occupational dose limit for the lens of eye, but at a heavy workload in the department, this dose limit could be achieved or exceeded. The use of protective lead glasses is recommended as they could reduce the radiation exposure of the lens of the eye. The phantom measurements demonstrated that the use of half-dose mode could additionally reduce dose to the operator's eye lens.
Evans, Christopher H.
Orthopaedic injuries are very common and a source of much misery and economic stress. Several relevant tissues, such as cartilage, meniscus and intra-articular ligaments, do not heal. And even bone, which normally regenerates spontaneously, can fail to mend. The regeneration of orthopaedic tissues requires four key components: cells, morphogenetic signals, scaffolds and an appropriate mechanical environment. Although differentiated cells from the tissue in question can be used, most cellular research focuses on the use mesenchymal stem cells (MSCs). These can be retrieved from many different tissues, and one unresolved question is the degree to which the origin of the cells matters. Embryonic and induced, pluripotential stem cells are also under investigation. Morphogenetic signals are most frequently supplied by individual, recombinant growth factors or native mixtures provided by, for instance, platelet-rich plasma; MSCs are also a rich source of trophic factors. Obstacles to the sustained delivery of individual growth factors can be addressed by gene transfer or smart scaffolds, but we still lack detailed, necessary information on which delivery profiles are needed. Scaffolds may be based upon natural products, synthetic materials, or devitalized extracellular matrix. Strategies to combine these components to regenerate tissue can follow traditional tissue engineering practices, but these are costly, cumbersome and not well suited to treating large numbers of individuals. More expeditious approaches make full use of intrinsic biological processes in vivo to avoid the need for ex vivo expansion of autologous cells and multiple procedures. Clinical translation remains a bottleneck. PMID:24182709
Suk, Michael; Udale, Ann Marie; Helfet, David L
Understanding the relevant legal context is critical to the safe and successful practice of orthopaedic surgery. Specifically, three areas of liability are relevant to most physicians: medical malpractice, products liability, and the liability of health care organizations. Medical malpractice encompasses the professional physician-patient relationship with its implied contract, consent, fiduciary responsibilities, and duty to provide the standard of care, as well as certain common-law duties pertinent in special circumstances. Orthopaedic surgeons who design implants or who have a relationship with a device manufacturer are at risk for liability for a failed product. In general, the hospital entity is responsible for the actions of its physician-employees. Still unclear is the degree to which a physician is obligated to appeal to a third-party payer on behalf of a patient. Physicians should remember that, above all else, common sense with regard to the treatment, informed consent, and advocacy of patients is essential to avoiding many medical-legal pitfalls.
Ochsner, Peter E
The different properties of bone must be considered in order to understand the relation between orthopaedic devices and bone. The epi-/metaphyseal areas are defined by their rigidity, their high vascularity and their quick remodelling process. In contrast, the diaphyses of bone are rather elastic and built of dense, scarcely vascularised bone presenting slow remodelling. Implants can integrate by pure mechanical contact without real affinity to bone or, alternatively, they can favour ongrowth of bone, provided that they are osteoconductive. Amongst different bone substitutes, only some of them are absorbable. Only derivates of bone may present the property of osteoinduction, which is the power to create new bone in any region of the body. Orthopaedic devices are characterised by their shape, their stiffness or elasticity and by the characteristic properties of material. They may be osteoconductive such as titanium alloys and some ceramics, allowing integration in bone. Alternatively, other materials such as steel, CoCr alloys and PMMA cements remain separated from bone by a tiny layer of collagen. The surface structure influences the quality of integration. The integration of implants depends on the mutual interaction of the material with the tissue on the implantation site. All implants undergo fatiguing which can lead to fracture of the implant. All implant-bone contacts are threatened by granulation tissue mainly formed because of wear products, infection and other reasons.
Eloranta, Sini; Katajisto, Jouko; Leino-Kilpi, Helena
The aim of this study was to explore orthopaedic nurses' perceptions of patient education practice; the educational skills of a nurse, the content, structure and educational approaches to patient education and its changes during nine years at a university hospital in Finland. The subjects of this survey were orthopaedic nurses at one university hospital - 56 nurses in 2001 and 51 nurses in 2010. On the whole, no statistically significant change had taken place in the nurses' patient education skills in the two periods compared. In 2001, the nurses discussed more often the learning objectives with patients compared to 2010. In both years, individual education sessions and written material were often used. In both years, the bio-physiological area of patient education was found to be dealt with most adequately, while the social area received less attention in 2010 than in 2001. According to our results, no change in a positive direction in nurses' patient education skills and the implementation of patient education can be seen over the past decade. The results of the study indicate clear development needs in patient education practice. Copyright © 2016 Elsevier Ltd. All rights reserved.
Wijenayake, Lahann; Conroy, Sophie; Turner, Douglas; Thorning, Sarah; Glasziou, Paul
The volume of orthopaedic literature is increasing exponentially, becoming more widely scattered among journals. The rate of increase in orthopaedics is greater than other specialties. We aimed to identify the number of different journals an orthopaedic surgeon would need to read to stay up-to-date with current evidence. We searched PubMed for all orthopaedic-related systematic reviews (SR) and randomized controlled trials (RCT) published in 2011 using MESH (Medical Subject Headings) terms. The search was based on the Australian Orthopaedic Association syllabus of March 2011. The results of the search were exported to EndNote, then Microsoft Excel. We then calculated the least number of journals needed to read 25%, 50% and 100% of the articles. This was done separately for SRs and RCTs. We found 1400 orthopaedic RCTs spread over 392 journals. Ten journals contained 25% of the articles, 36 journals contained 50% and 114 journals contained 75%. Three hundred journals contained three or fewer RCTs. We found 354 orthopaedic-relevant SRs spread over 152 journals. Six journals contained 25% of the articles, 23 journals contained 50% and 63 journals contained 75%. Ninety-three journals contained only one SR. Our results demonstrate the vast scatter of orthopaedic research. Four orthopaedic RCTs are published every day. To read even 25% of the new RCTs and SRs published in orthopaedics, a surgeon would require a subscription to 13 different journals monthly, a costly and time-consuming endeavour. © 2014 Royal Australasian College of Surgeons.
McSorley, K; Quinlan, J
Trauma is a major source of mortality and morbidity throughout Ireland. Training in trauma is dependant on experience gained by trainees within specific posts. Trauma services are a topical issue at present with much discussion about delivery and restructuring. With this in mind we conducted an online survey of trainees in emergency medicine, orthopaedic and general surgery to assess current experience and opinions with regard to trauma. The survey was vetted and distributed by the relevant training bodies. 59(98.33%) respondents believed smaller units should be bypassed for major trauma and 55 (91.67%) believed that larger hospitals receiving major trauma should have a trauma theatre available 24-hours a day. 55 (91.67%) also foresaw themselves covering major trauma as consultants, consequently these trainees will be the consultants developing, moulding and working in this restructured trauma service.
Mathew, George; Sancheti, Parag; Jain, Anil; Bhandari, Mohit
Road traffic accidents are increasing at an alarming rate and have become a major public health concern in India. In addition, there is a lack of trauma research output and reliable data from India. There are several issues and challenges that have presented an opportunity for researchers and surgeons in India to develop a collaborative aimed at improving the quality and productivity of orthopaedic trauma research. Establishing a network of surgical researchers across India is a necessary first step towards global leadership in orthopaedic surgery trials. PMID:19826521
Gausden, Elizabeth B; Christ, Alexander B; Zeldin, Roseann; Lane, Joseph M; McCarthy, Moira M
The purpose of this study was to determine the amount of cumulative radiation exposure received by orthopaedic surgeons and residents in various subspecialties. We obtained dosimeter measures over 12 months on 24 residents and 16 attending surgeons. Monthly radiation exposure was measured over a 12-month period for 24 orthopaedic residents and 16 orthopaedic attending surgeons. The participants wore a Landauer Luxel dosimeter on the breast pocket of their lead apron. The dosimeters were exchanged every rotation (5 to 7 weeks) for the resident participants and every month for the attending surgeon participants. Radiation exposure was compared by orthopaedic subspecialty, level of training, and type of fluoroscopy used (regular C-arm compared with mini C-arm). Orthopaedic residents participating in this study received monthly mean radiation exposures of 0.2 to 79 mrem/month, lower than the dose limits of 5,000 mrem/year recommended by the United States Nuclear Regulatory Commission (U.S. NRC). Senior residents rotating on trauma were exposed to the highest monthly radiation (79 mrem/month [range, 15 to 243 mrem/month]) compared with all other specialty rotations (p < 0.001). Similarly, attending orthopaedic surgeons who specialize in trauma or deformity surgery received the highest radiation exposure of their peers, and the mean exposure was 53 mrem/month (range, 0 to 355 mrem/month). Residents and attending surgeons performing trauma or deformity surgical procedures are exposed to significantly higher doses of radiation compared with all other subspecialties within orthopaedic surgery, but the doses are still within the recommended limits. The use of ionizing radiation in the operating room has become an indispensable part of orthopaedic surgery. Although all surgeons in our study received lower than the yearly recommended dose limit, it is important to be aware of how much radiation we are exposed to as surgeons and to take measures to further limit that exposure.
Canillas, Fernando; Gómez-Ramírez, Susana; García-Erce, José Antonio; Pavía-Molina, José; Gómez-Luque, Aurelio; Muñoz, Manuel
Orthopaedic and trauma surgical procedures (OTS) can lead to significant blood losses and acute postoperative anaemia, which in many cases requires allogeneic blood transfusions (ABT). The clinical, economic and logistical disadvantages of ABT have promoted the development of multidisciplinary and multimodal programs generically known as Patient Blood Management (PBM) programs, which have as their objective to reduce or eliminate the need for ABT and improve clinical outcomes. These programs are supported by the implementation of four groups of perioperative measures: (1) use of restrictive transfusion criteria; (2) stimulation of erythropoiesis; (3) reduction of bleeding; and (4) autologous blood transfusion. In this article, a review is presented of the effectiveness, safety and recommendations of applicable strategies in OTS, as well as the barriers and requirements to the development and implementation of PBM programs in this surgical specialty.
Devanathan, D.; Levine, D.
With the increasing demand for superior performance placed on present day orthopaedic devices, there exists a constant demand to look for better materials for construction. Because of their good corrosion resistance, early devices were made from 304 or 316 stainless steels. However, the patient population has broadened to include younger individuals. These patients lead active lives and tend to stress the fracture fixation devices. Another requirement for younger patients is a longer implantable service: up to 20 years. With these requirements in mind, high-performance aerospace metal alloys based on cobalt chromium and titanium are used extensively. This paper discusses the requirements and the deficiencies of new materials; biocompatibility, biofunctionality, and manufacturing costs.
Varghese, Ranjit A; Dhawale, Arjun A; Zavaglia, Bogard C; Slobogean, Bronwyn L; Mulpuri, Kishore
The purpose of this study was to identify the clinical pediatric orthopaedic articles with at least 100 citations published in all orthopaedic journals and to examine their characteristics. All journals dedicated to orthopaedics and its subspecialties were selected from the Journal Citation Report 2001 under the subject category "orthopedics." Articles cited 100 times or more were identified using the database of the Science Citation Index Expanded (SCI-EXPANDED, 1900 to present). The articles were ranked in a comprehensive list. Two authors independently reviewed the full text of each article and applied the inclusion and exclusion criteria to the list of articles. The 2 lists were then compared. All disagreements were resolved by consensus with input from the senior author. The final list of pediatric orthopaedic articles was then compiled. There were a total of 49 journals under the search category "orthopedics." Five journals were excluded as they were non-English journals. The remaining 44 journals were screened for articles with at least 100 citations. A total of 135 clinical pediatric orthopaedic articles cited at least 100 times were included. The most cited article was cited 692 times. The mean number of citations per article was 159 (95% confidence interval, 145-173). All the articles were published between 1949 and 2001, with 1980 and 1989 producing the most citation classics (34). The majority (90) originated from the United States, followed by the United Kingdom (12) and Canada (11). Scoliosis/kyphosis was the most common topic with 26 papers. The second most common subject was hip disorders (24). Therapeutic studies were the most common study type (71). Ninety-seven papers were assigned a 4 for level of evidence. The list of citation classics in pediatric orthopaedic articles is useful for several reasons. It identifies important contributions to the field of pediatric orthopaedics and their originators; it facilitates the understanding and discourse
Karavias, D; Korovessis, P; Filos, K S; Siamplis, D; Petrocheilos, J; Androulakis, J
Seventeen patients, aged 11-67 years (mean, 32.6), with major vascular injuries associated with traumatic orthopaedic injuries, were treated operatively in the authors' institution over a 4-year period. The most common mechanism of trauma was a high-energy injury (70.8%), and the rate of open injuries was 88.2%; 64.9% of the injuries were located in the lower extremities. The treatment protocol consisted of aggressive resuscitation; Doppler imaging and, when necessary, angiography; stable bone fixation with subsequent vascular repair; and extended wound debridement. The vascular repair for arterial lacerations consisted of (a) end-to-end anastomosis (47.2%); (b) interpositional homologous vein graft (23.6%); (c) vascular decompression through fracture distraction in one patient (5.9%); (d) xenograft interposition (in one patient; 5.9%); (e) venous repair (in three patients; 17.7%); and (f) embolectomy (in all patients). Three vascular reoperations (17.7%) were necessary because of rupture of the anastomosis. The authors' preferred bone stabilization method was external fixation, which was used in 47.2% of cases. Amputation was performed in three cases (17.7%) as a salvage operation. Although six patients (35.4%) were admitted with delayed shock (mean duration, 73.6 +/- 27.8 min), this led to a lethal outcome due to shock lung in only one patient. Another patient developed massive lung embolism 3 months postoperatively and died. The authors believe that this well-organized approach, based on a specific treatment protocol, for patients with severe orthopaedic trauma and concomitant vascular injury, not only improves outcome but gives good to excellent functional results in the majority of patients.
Background The CRASH-2 trial showed that early administration of tranexamic acid (TXA) safely reduces mortality in bleeding in trauma patients. Based on data from the CRASH-2 trial, global mortality data and a systematic literature review, we estimated the number of premature deaths that might be averted every year worldwide through the use of TXA. Methods We used CRASH-2 trial data to examine the effect of TXA on death due to bleeding by geographical region. We used WHO mortality data (2008) and data from a systematic review of the literature to estimate the annual number of in-hospital trauma deaths due to bleeding. We then used the relative risk estimates from the CRASH-2 trial to estimate the number of premature deaths that could be averted if all hospitalised bleeding trauma patients received TXA within one hour of injury, and within three hours of injury. Sensitivity analyses were used to explore the effect of uncertainty in the parameter estimates and the assumptions made in the model. Results There is no evidence that the effect of TXA on death due to bleeding varies by geographical region (heterogeneity p = 0.70). Based on WHO data and our systematic literature review, we estimate that each year worldwide there are approximately 400,000 in-hospital trauma deaths due to bleeding. If patients received TXA within one hour of injury then approximately 128,000 (uncertainty range [UR] ≈ 72,000 to 172,000) deaths might be averted. If patients received TXA within three hours of injury then approximately 112,000 (UR ≈ 68,000 to 148,000) deaths might be averted. Country specific estimates show that the largest numbers of deaths averted would be in India and China. Conclusions The use of TXA in the treatment of traumatic bleeding has the potential to prevent many premature deaths every year. A large proportion of the potential health gains are in low and middle income countries. PMID:22380715
Smith, Mary Atkinson; Walsh, Colleen; Levin, Barbara; Eaten, Kathyrn; Yager, Melissa
The potential for adverse events exists when treating and managing orthopaedic patients in the intraoperative or postoperative environments, especially when it comes to falls, surgical site infections, venous thromboembolism, and injuries to nerves and blood vessels. Orthopaedic nurses play a vital role in the promotion and use of evidence-based interventions to decrease the incidence of these adverse events, improve quality of care, and minimize the financial burden related to these adverse events.
Vaughan, Neil; Dubey, Venketesh N; Wainwright, Thomas W; Middleton, Robert G
This review presents current virtual reality based training simulators for hip, knee and other orthopaedic surgery, including elective and trauma surgical procedures. There have not been any reviews focussing on hip and knee orthopaedic simulators. A comparison of existing simulator features is provided to identify what is missing and what is required to improve upon current simulators. In total 11 hip replacements pre-operative planning tools were analysed, plus 9 hip trauma fracture training simulators. Additionally 9 knee arthroscopy simulators and 8 other orthopaedic simulators were included for comparison. The findings are that for orthopaedic surgery simulators in general, there is increasing use of patient-specific virtual models which reduce the learning curve. Modelling is also being used for patient-specific implant design and manufacture. Simulators are being increasingly validated for assessment as well as training. There are very few training simulators available for hip replacement, yet more advanced virtual reality is being used for other procedures such as hip trauma and drilling. Training simulators for hip replacement and orthopaedic surgery in general lag behind other surgical procedures for which virtual reality has become more common. Further developments are required to bring hip replacement training simulation up to date with other procedures. This suggests there is a gap in the market for a new high fidelity hip replacement and resurfacing training simulator. Copyright © 2015 IPEM. Published by Elsevier Ltd. All rights reserved.
Chung, Jonathan H; Strigel, Roberta M; Chew, Annemarie Relyea; Albrecht, Emily; Gunn, Martin L
At the authors' level 1 trauma center, postgraduate year 3 and 4 radiology residents interpret urgent overnight imaging studies, which are reviewed by attending radiologists the next morning. The goals of this study were to determine the discrepancy rate for torso computed tomography between resident radiologists' preliminary interpretations and attending radiologists' final interpretations and to identify adverse patient events secondary to the delayed diagnoses. All torso computed tomographic studies interpreted by weekday night residents (8 pm to 8 am) from January 1, 2005, to March 13, 2007, were evaluated retrospectively. Major discrepancies between the residents' interpretations and the attending radiologists' interpretations were compiled. Exams with major discrepancies were additionally reviewed by two radiology residents and an attending emergency radiologist. The medical records of patients with major discrepant findings were also reviewed to identify adverse events that occurred because of the delays in final interpretation. A total of 4768 chest, abdominal, and/or pelvic computed tomographic studies were interpreted during the study period. A total of 112 major discrepancies were collected. In 17 cases (15%), two additional radiology residents and an attending emergency radiologist agreed with the initial residents' interpretations, decreasing the major discrepancy rate to 95 of 4768 (2.0%), consistent with data from the literature (0.4%-10%). Management was changed in 16 patients (0.3%) because of the major discrepancies: 13 patients underwent additional investigations, and 3 patients were recalled to the emergency room. No mortality or morbidity was directly attributed to the delays in diagnosis. At the authors' institution, there was a 2.0% discrepancy rate between residents' preliminary interpretations and attending radiologists' final interpretations of overnight torso computed tomography, with a small rate of additional intervention as a result of
Morris, Joanne H; James, Rebecca E; Davey, Rachel; Waddington, Gordon
Rationale, aims and objectives Complex and chronic disease is placing significant pressure on hospital outpatient departments. Novel ways of delivering care have been developed recently and are often described as ‘triage’ services. This paper reviews the literature pertaining to definitions and descriptions of orthopaedic/musculoskeletal triage processes, in order to provide information on ‘best practice’ to assist health care facilities. Method A comprehensive open-ended search was conducted using electronic databases to identify studies describing models of triage clinics for patients with a musculoskeletal/orthopaedic complaint, who have been referred to hospital outpatient clinics for a surgical consultation. Studies were critically appraised using the McMaster quality appraisal tool and ranked using the National Health and Medical Research Council hierarchy of evidence. A thematic analysis of the definitions, processes and procedures of triage described within the literature was undertaken. Results 1930 studies were identified and 45 were included in the review (including diagnostic and evaluative research). The hierarchy of evidence ranged from I to IV; however, the majority were at low levels of evidence and scored poorly on the critical appraisal tool. Three broad themes of triage were identified: presence of a referral, configuration of the triage (who, how and where) and the aim of triage. However, there were significant inconsistencies across these themes. Conclusions This systematic review highlighted the need for standardization of the definition of triage, the procedures of assessment and management and measures of outcome used in orthopaedic/musculoskeletal triage to ensure best-practice processes, procedures and outcomes for triage clinics. PMID:25410703
Yang, Yi; Reid, Chris; Nambiar, Mithun; Penn, David
Hydrogen peroxide (H2O2) is commonly used in orthopaedic surgery during cemented arthroplasty and wound washouts. Its purported roles include antisepsis, haemostasis, mechanical debridement, and optimising the cement-bone interface during cementing. However, despite its apparent harmless mechanism of action, H2O2 has been implicated in fatal and near fatal complications caused through oxygen emboli. We present a case of oxygen embolism and review the existing literature to highlight its potential risks and its lack of therapeutic value. We believe there is little role for its use in orthopaedic surgery.
Ó Mír, M; O'Sullivan, C
One in eight paediatric primary care presentations is for a musculoskeletal (MSK) disorder. These patients are frequently referred to paediatric orthopaedic surgeons; however, up to 50% of referrals are for normal variants. This results in excessive wait-times and impedes access for urgent surgical cases. Adult MSK medicine has successfully utilised advanced practice physiotherapists (APP) managing non-surgical candidates, with documented benefits both to patients and services. There is a gap in the literature with regard to APP in paediatric orthopaedics. In this review, we investigate demands on paediatric orthopaedic services, examine the literature regarding APP in paediatric orthopaedics and explore the value the role has to offer current outpatient services. Paediatric orthopaedic services are under-resourced with concurrent long wait times. Approximately 50% of referrals are for normal variants, which do not require specialist intervention. Poor musculoskeletal examination skills and low diagnostic confidence amongst primary care physicians have been identified as a cause of inappropriate referrals. APP clinics for normal variants have reported independent management rate and discharge rates of 95% and marked reduction in patient wait times. There is limited evidence to support the APP in paediatric orthopaedics. Further studies are needed investigating diagnostic agreement, patient/stakeholder satisfaction, patient outcomes and economic evaluation. Paediatric orthopaedics is in crisis as to how to effectively manage the overwhelming volume of referrals. Innovative multidisciplinary solutions are required so that the onus is not solely on physicians to provide all services. The APP in paediatric orthopaedics may be part of the solution.
Campbell, Carole L.; Brown, Elissa J.; Okwara, Leonore
Research has documented increases in child maltreatment at times when caregivers are deployed and rates have increased among military families since 2002, despite remaining stable among civilian families. Military youth also are susceptible to traumatic events that are nonmilitary related. Despite the prevalence of various forms of trauma exposure…
Campbell, Carole L.; Brown, Elissa J.; Okwara, Leonore
Research has documented increases in child maltreatment at times when caregivers are deployed and rates have increased among military families since 2002, despite remaining stable among civilian families. Military youth also are susceptible to traumatic events that are nonmilitary related. Despite the prevalence of various forms of trauma exposure…
Lansky, David; Nwachukwu, Benedict U; Bozic, Kevin J
A variety of reforms to traditional approaches to provider payment and benefit design are being implemented in the United States. There is increasing interest in applying these financial incentives to orthopaedics, although it is unclear whether and to what extent they have been implemented and whether they increase quality or reduce costs. We reviewed and discussed physician- and patient-oriented financial incentives being implemented in orthopaedics, key challenges, and prerequisites to payment reform and value-driven payment policy in orthopaedics. We searched the MEDLINE database using as search terms various provider payment and consumer incentive models. We retrieved a total of 169 articles; none of these studies met the inclusion criteria. For incentive models known to the authors to be in use in orthopaedics but for which no peer-reviewed literature was found, we searched Google for further information. Provider financial incentives reviewed include payments for reporting, performance, and patient safety and episode payment. Patient incentives include tiered networks, value-based benefit design, reference pricing, and value-based purchasing. Reform of financial incentives for orthopaedic surgery is challenged by (1) lack of a payment/incentive model that has demonstrated reductions in cost trends and (2) the complex interrelation of current pay schemes in today's fragmented environment. Prerequisites to reform include (1) a reliable and complete data infrastructure; (2) new business structures to support cost sharing; and (3) a retooling of patient expectations. There is insufficient literature reporting the effects of various financial incentive models under implementation in orthopaedics to know whether they increase quality or reduce costs. National concerns about cost will continue to drive experimentation, and all anticipated innovations will require improved collaboration and data collection and reporting.
Schneiders, W; Dittmann, U; Hannemann, F; Jäger, M; Eberlein-Gonska, M; Schaser, K D; Zwipp, H; Günther, K-P
Background: Since the combination of orthopaedic and traumatology surgery as a single speciality, an extremely wide variety of orthopaedic and trauma surgery centres have been founded in Germany. The present investigation analysed the degree to which additional value has been generated by merging two previously independent university departments - one for orthopaedics, the other for trauma surgery - into a single orthopaedics and trauma surgery centre. Material and Methods: The centre, merged in 1 June 2013, is led by two equal co-chairs (a full professor for orthopaedics and a full professor for trauma surgery). It consists of an acute division and five other divisions for specific parts of the body. The pre-existing certifications (level 1 trauma- and joint arthroplasty centre) were maintained in the new merged entity. Data from patient and employee questionnaires, as well as key economic indicators, were compared before and after the merger. Results: 11 % of the patients rated the medical treatment as mediocre or bad before the merger. After the merger, 5.7 % of the patients were moderately satisfied or unsatisfied; 92 % would recommend the merged centre to others and would return for further treatment. The evaluation of patient complaints before and after the merger showed no change. The evaluation of the employee questionnaires showed heterogeneous results. Overall, positive evaluations predominated, but in areas where there had been major changes, negative aspects were occasionally reported. The merger did not bring about any essential change in the number of in-patients (2012: 6693; 2014: 6649) or in the severity of the medical cases (CMI in 2012: 1.41; in 2014: 1.45). But in 2015, there was an increase in the number of in-patients (6837) and in the CMI (1.54). In the out-patient clinic, the merger led to a reduction in the material costs per patient (2012: 3.53 €/patient; 2014: 3.07 €/patient) and in the staff costs. The material costs for the
15 patients including several who were shot, others who were severely injured in other ways and four who ultimately died. Despite the small number...their most profound social consequences in the loss of young adults from the working population. Injury is the most common cause of the loss of years...who have an injury severity score of > 15 and must have a trauma surgeon, anaesthesiologist, orthopaedic surgeon, thoracic surgeon and neurosurgeon
Bae, Donald S
Surgical simulation has become an increasingly important means of improving skills acquisition, optimizing clinical outcomes, and promoting patient safety. While there have been great strides in other industries and other fields of medicine, simulation training is in its relative infancy within pediatric orthopaedics. Nonetheless, simulation has the potential to be an important component of Quality-Safety-Value Initiative of the Pediatric Orthopaedic Society of North America (POSNA). The purpose of this article will be to review some definitions and concepts related to simulation, to discuss how simulation is beneficial both for trainee education as well as value-based health care, and to provide an update on current initiatives within pediatric orthopaedic surgery.
This article revisits the application of orthopaedic service lines from early introduction and growth of this organizational approach in the 1980s, through the 1990s, and into the current decade. The author has experienced and worked in various service-line structures through these three decades, as well as the preservice-line era of 1970s orthopaedics. Past lessons learned during earlier phases and then current trends and analysis by industry experts are summarized briefly, with indication given of the future for service lines. Variation versus consistency of certain elements in service-line definitions and in operational models is discussed. Main components of service-line structures and typical processes are described briefly, along with a more detailed section on the service-line director/manager role. Current knowledge contained here will help guide the reader to more "out-of-the-box" thinking toward comprehensive orthopaedic centers of excellence.
Calderon-Miranda, Willen Guillermo; Alvis-Miranda, Hernando Raphael; M Rubiano, Andres; Moscote-Salazar, Luis Rafael
Traumatic brain injury is a common entity. However cerebral infarction in infants is a rare entity while the diagnosis of this pathology in the pediatric population is usually difficult. The mild head trauma is rarely accompanied by intracranial injury and even less, with cerebral infarction. We herein report the first case of cerebral infarction after a mild brain trauma in a 2-year-old Latin-American male patient, in which brain computed tomography (CT) scan was performed on the first day of the accident, showed right hemispheric cerebral ischemia compromising the fronto-parieto-occipital region. Conservative management was established. The patient died at day 5. So Brain CT scan may be beneficial to reveal any hemispheric infarction due to a probable mass effect.
Mukherjee, Kanchan Kumar; Mohindra, Sandeep; Gupta, Sunil Kumar; Gupta, Rahul; Khosla, Virender Kumar
Traumatic acute SDH in pediatric patients is a life-threatening situation. There is a severe increase in ICP caused by acute SDH or diffuse brain swelling or secondary to ischemic brain damage. In certain situations, conventional measures may fail to control such a rapid increase in ICP. The cases of 4 pediatric patients with cranial trauma with raised ICP, in whom hemicranial decompression was performed, are described. All patients had acute SDH with diffuse brain injury; in addition, 2 of them had associated massive infarcts. Three of them survived and had a favorable outcome. In certain situations, pediatric patients with cranial trauma may be offered hemicranial decompression as a surgical option. These children may have a better long-term outcome despite massive infarcts.
... education site of the American Orthopaedic Foot & Ankle Society. Patients Visit the official patient education site of the American Orthopaedic Foot & Ankle Society. Patients Visit the official patient education site of ...
Valle, Joaquin; Srinivasrao, Hanumantha; Snow, David; Asbitt, Mike
While elderly patients account for only 10-12% of all trauma victims, they consume 25% of trauma-related health care resources, with higher rates of mortality and complication. Presently described is the case of an elderly patient who presented to the emergency department (ED) following mild thoracic trauma, with previous history of gastric pull-up surgery. The patient had consulted another facility 48 hours earlier and was prescribed analgesia and x-ray follow-up for a mechanical fall and pain in the lower rib cage. At arrival, the patient complained of increasing dyspnea and pain at the right hemithorax. X-ray showed right hemithorax effusion, and contrast computed tomography (CT) demonstrated a large amount of contrast filling the pleural space and a relatively small point of gastric pull-up rupture in the stomach. The patient was referred to the cardiothoracic unit, but was unresponsive upon arrival and died. The aim of the present report was to raise the index of clinical suspicion of traumatic rupture of the gastric pull-up following traumatic chest injury, and to affirm that contrast CT should be the gold standard for diagnosis.
Nagaveni, N B; Umashankara, K V
Traumatic injuries to maxillary anterior teeth are a common finding in children because of falls while playing. Sequelae of trauma to dental hard tissue include broken, lost, aspirated and swallowed teeth. One additional hazard is the embedding of fractured tooth fragments in the soft tissues, particularly in the lip. A 10-year-old male patient complained of pain in the lower lip. There was a history of trauma to the upper anterior tooth 10 months previously. Clinical examination showed scarring and discoloration over the lower lip, and the presence of a hard mass was felt on palpation. Intraoral examination revealed an Ellis and Davey class II fracture of number 11. A radiograph of the lip was taken, which showed a radiopaque structure similar to the shape of the missing tooth fragment. Under local anesthesia, the tooth fragment was removed successfully, and the class II fracture was restored with composite. Therefore, proper clinical and complete radiographic examination of both hard and soft tissues following dental trauma is essential to rule out such occurrences.
Suryavanshi, Tanishq; Geier, C David; Leland, J Martin; Silverman, Lance; Duggal, Naven
Social media presents unique opportunities and challenges for practicing orthopaedic surgeons. Social media, such as blogging, Facebook, and Twitter, provides orthopaedic surgeons with a new and innovative way to communicate with patients and colleagues. Social media may be a way for orthopaedic surgeons to enhance communication with patients and healthcare populations; however, orthopaedic surgeons must recognize the limitations of social media and the pitfalls of increased connectedness in patient care.
Caird, Michelle S
Patients, surgeons, and staff are exposed to ionizing radiation in pediatric orthopaedic surgery from diagnostic studies and imaging associated with procedures. Estimating radiation dose to pediatric patients is based on complex algorithms and dose to surgeons and staff is based on dosimeter monitoring. Surgeons can decrease radiation exposure to patients with careful and thoughtful ordering of diagnostic studies and by minimizing exposure intraoperatively. Surgeon and staff radiation exposure can be minimized with educational programs, proper shielding and positioning intraoperatively, and prudent use of intraoperative imaging. Overall, better awareness among pediatric orthopaedic surgeons of our role in radiation exposure can lead to improvements in radiation safety.
Mattox, Kenneth L; Goetzl, Laura
The objective of this article was to review the existing standards of practice regarding trauma which occurs during pregnancy. The design of this study was to review the available data from the surgical and obstetrical literature regarding trauma during pregnancy. The design was also to incorporate the contemporary recommendations from the trauma resuscitation courses relating to trauma during pregnancy. Trauma occurs in 5% of pregnancies. A fetus is not considered to be viable until week 25. Motor vehicle accidents account for more than 50% of all trauma during pregnancy, with 82% of fetal deaths occurring during these automobile accidents. With life threatening trauma a 50% fetal loss rate exists. As anatomy, physiology, and even laboratory findings change during pregnancy, the clinician must consider both patients, the mother and fetus. Following blunt trauma abruption of the placenta is the more common cause of fetus loss. Anterior abdominal penetrating trauma almost never fails to injury the uterus and fetus in the last half of pregnancy. Preventive strategies exist in the areas of social violence, automobile restraints and use of alcohol and drugs by the mother. Perimortem caesarian section is rarely successful. Trauma during pregnancy is uncommon, but with increasing trauma severity leads to increased fetal loss. Preventive strategies exist and when admitted monitoring standards should be followed.
Davidson, Donald J; Rankin, Kenneth S; Jensen, Cyrus D; Moverley, Robert; Reed, Mike R; Sprowson, Andrew P
Advertisements are commonplace in orthopaedic journals and may influence the readership with claims of clinical and scientific fact. Since the last assessment of the claims made in orthopaedic print advertisements ten years ago, there have been legislative changes and media scrutiny which have shaped this practice. The purpose of this study is to re-evaluate these claims. Fifty claims from 50 advertisements were chosen randomly from six highly respected peer-reviewed orthopaedic journals (published July-December 2011). The evidence supporting each claim was assessed and validated by three orthopaedic surgeons. The assessors, blinded to product and company, rated the evidence and answered the following questions: Does the evidence as presented support the claim made in the advertisement and what is the quality of that evidence? Is the claim supported by enough evidence to influence your own clinical practice? Twenty-eight claims cited evidence from published literature, four from public presentations, 11 from manufacturer "data held on file" and seven had no supporting evidence. Only 12 claims were considered to have high-quality evidence and only 11 were considered well supported. A strong correlation was seen between the quality of evidence and strength of support (Spearman r = 0.945, p < 0.0001). The average ICC between the assessors' ratings was strong (r = 0.85) giving validity to the results. Orthopaedic surgeons must remain sceptical about the claims made in print advertisements. High-quality evidence is required by orthopaedic surgeons to influence clinical practice and this evidence should be sought by manufacturers wishing to market a successful product.
Rai, Rahul; Sabharwal, Sanjeev
Retracted publications are a crucial, yet overlooked, issue in the scientific community. The purpose of our study was to assess the prevalence, characteristics, and trends of retracted publications in the field of orthopaedics. Five databases were utilized to identify retracted publications in orthopaedics. The cited articles were assessed for various characteristics, including reason for retraction, based on the Committee on Publication Ethics (COPE) guidelines and trends over time. From 1984 to June 4, 2016, 59 of 229,502 orthopaedic publications were retracted (3 per 10,000 articles). There was a spike in the prevalence (22 of 59) of retracted articles in 2015. When compared with the total number of retracted publications identified through PubMed, the field of orthopaedics represented 1.4% of all retracted publications. The original version of 47 of these 59 retracted publications was still available on the respective journal's web site; 14 (30%) of these were not noted as having been retracted. The mean time from electronic publication to retraction was 19.4 ± 23.3 months. The mean number of citations of a retracted publication after the date of retraction was 9.3 ± 19.3. Reasons for retraction included plagiarism (32%), misconduct (27%), redundant publication (22%), miscalculation or experimental error (8%), and unethical research (0%); the reason for retraction was not stated for 10% of the publications. There was no correlation between a journal's impact factor and the mean number of months to retraction (p = 0.564). While uncommon, the retraction of publications within the field of orthopaedics may be increasing. The most often cited reasons for retraction were plagiarism, misconduct, and redundant publication. Retracted articles continue to be cited in the literature after retraction. Greater awareness of the COPE guidelines within the orthopaedic community and more efficient means to prevent the citation of retracted articles are needed.
Jastifer, James R; Toledo-Pereyra, Luis H; Gustafson, Peter A
Galileo Galilei (1564-1642), world-renowned Italian mathematician, astronomer, physicist and philosopher, made many contributions to science. The objective of this study is to demonstrate that Galileo's discovery of scaling principles permitted others to define and advance orthopaedic research and clinical sciences. The science and scaling principles of Galileo Galilei were extensively analyzed by reviewing his 1638 original work Discorsi e Demostrazioni Matematiche Intorno a Due Nuove Scienze. Works about Galileo's science were reviewed for the concept of the scaling principles and with the idea of shedding light on how his work influenced modern orthopaedics. Galileo strictly adhered to the Copernican heliocentric theory with the sun at the center of the universe, which caused him aggravation and made him the target of inquisition rage at the end of his prodigious life. With his attention away from the cosmos, Galileo--through the voices of Salviati, Sagredo and Simplicio in the Discourses on Two New Sciences--defined how scaling was important to the movement and function of objects. Galileo introduced important advances in scaling laws, which contributed to the development of the field of biomechanics. This discipline, in many ways, has defined modern clinical and research orthopaedics. Galileo, by introducing the principles of scaling, permitted their application to human physical capacity, to bone and tissue response after injury, and to clinical treatment of injuries. Galileo in this way made important contributions to the practice of modern orthopaedics.
Tasker, L H; Sparey-Taylor, G J; Nokes, L D M
Nanotechnology is the application of science and engineering at the nanoscale. A diverse range of applications are beginning to emerge in all areas of medicine. We performed a survey from November 2005 to March 2006 using the Internet search engines PubMed, ScienceDirect, ISI Web of Knowledge, and Google Scholar. We report on the role of nanotechnology in orthopaedics, exploring current and potential applications. Nanostructured materials have been proposed as the next generation of orthopaedic implant properties by creating a surface environment more conducive for osteoblast function. Bone substitute materials, whose nanoscale composition emulates the hierarchic organization of natural bone, shows initiation of the desirable formation of an apatite layer. Nanotechnology also has been harnessed to improve the cutting performance and quality of surgical blades. Postoperative infection rates may be reduced by using nanofibrous membrane wound dressings containing antibacterial properties. The most notable application of nanotechnology in orthopaedics may be drug delivery, including nanotherapeutics for treating bone cancer and arthritis. Nanotechnology is being used in orthopaedics, and likely will play a valuable role in future developments.
This book discusses topics on orthopaedic medicine. Treatments, radiographic findings, and potential complications are provided for the complete scope of musculoskeletal problems. It reviews the latest diagnostic techniques, including arthroscopy and CT scanning and also gives updates on the newest approaches to the management of skeletal infections, the latest on joint replacements, and offers a review of arthroscopic surgery.
Smith, Brian G; Kanel, Jeffrey S; Halsey, Matthew F; Thometz, John G; Rosenfeld, Samuel R; Epps, Howard R; McCarthy, James
The emergency room on-call status of pediatric orthopaedic surgeons is an important factor affecting their practices and lifestyles and was last evaluated in 2006. The entire membership of the Pediatric Orthopaedic Society of North America (POSNA) was surveyed in 2010 for information regarding their emergency room on-call status with 382 surveys returned of over 1000 e-mailed to members of POSNA. Detailed information about on-call coverage, support, and frequency was obtained in answers to 14 different questions. Compared with the prior survey in 2006, the 2010 survey indicated that a higher percentage of pediatric orthopaedic surgeons receive compensation for taking emergency room call; a higher percentage cover pediatric patients only when on-call; and accessibility to operating rooms in a timely manner for trauma cases, although limited, has improved for pediatric patients. Utilization of support staff to meet on-call trauma coverage demands, such as residents, physician's assistants, and nurse practitioners, is becoming more common. Concentration of pediatric orthopaedic trauma has increased the coverage demands on pediatric orthopaedists. This has resulted in a change in reimbursement strategies, and allocation of OR time and hospital staffing resources.
Millar, Ian L; McGinnes, Rosemary A; Williamson, Owen; Lind, Folke; Jansson, Karl-Åke; Hajek, Michal; Smart, David; Fernandes, Tiago; Miller, Russell; Myles, Paul; Cameron, Peter
Introduction Open fractures with significant soft tissue injury are associated with high rates of complications, such as non-union, infection, chronic pain and disability. Complications often require further inpatient care, and in many cases, multiple operations and prolonged rehabilitation. Use of hyperbaric oxygen therapy as an adjunct to standard orthopaedic trauma care has the potential to reduce the complications of musculoskeletal injury and thus improve outcomes. Two previous randomised trials have suggested some positive effect, but neither functional measures nor long-term outcomes were reported. Methods and analysis An international, multicentre, randomised, open-label, clinical trial. Patients with trauma with an acute open fracture of the tibia with severe soft tissue injury (Gustilo grade 3) and high risk of injury-related complications were recruited from participating major trauma hospitals with hyperbaric facilities. Patients were enrolled with the expectation of commencing 12 sessions of hyperbaric oxygen therapy within 48 h of injury. The primary outcome measure is the incidence of acute complications of the open fracture wound at 14 days. Other short-term outcome measures include amputation, need for fasciotomy, time until wound closure, breakdown of closed wounds, time until definitive orthopaedic fixation, number of operative procedures, intensive care stay and hospital stay. Long-term follow-up will continue for 2 years postinjury. Ethics and dissemination Ethics approval was given by The Alfred Health Human Ethics Committee (206/04) and the Monash University Human Research Ethics Committee (CF07/4208). Approval was also obtained from the institutional research ethics committee at each participating site. This study will make a significant contribution to the trauma literature and should answer the question of whether hyperbaric oxygen therapy can significantly improve outcomes in severe lower limb trauma. Collective study results will
Alwattar, Basil J; Schwarzkopf, Ran; Kirsch, Thorsten
Stem cell application is a burgeoning field of medicine that is likely to influence the future of orthopaedic surgery. Stem cells are associated with great promise and great controversy. For the orthopaedic surgeon, stem cells may change the way that orthopaedic surgery is practiced and the overall approach of the treatment of musculoskeletal disease. Stem cells may change the field of orthopaedics from a field dominated by surgical replacements and reconstructions to a field of regeneration and prevention. This review will introduce the basic concepts of stem cells pertinent to the orthopaedic surgeon and proceed with a more in depth discussion of current developments in the study of stem cells in fracture healing.
Mehlman, Charles T; Wenger, Dennis R
An important event in the modern history of pediatric orthopaedics was the establishment of a journal dedicated to the subspecialty in 1981. Twenty-five years' worth of articles within the Journal of Pediatric Orthopaedics was subjected to citation analysis with the intention of identifying the 25 most frequently cited articles. Four true classic articles emerged (>or=100 citations). When looking at all articles on the top 25 list, the most common study design was retrospective in nature, and the most common subject matter was cerebral palsy and trauma-related topics.
Holzer, Lukas A; Holzer, Gerold
To give an overview of the behaviour and scientific contributions of the Journal of Bone and Joint Surgery American (JBJS-A) and British Volume (JBJS-B). 480 original articles published in 2009 were identified through a combined comprehensive computer and manual library search. Articles were assigned to 11 orthopaedic categories and by country, type and specialty of the institution. Possible grants and citations were analysed. USA led all countries in published articles (36,87%), followed by UK (20,62%) and South Korea (5,83%). Most studies published were performed at academic institutions (65,83 %), only 4,16% at private practices. Almost half of the articles (46,24%) were published in three categories: hip (19.16%), knee (13.75%) and trauma (13.33%). In both journals 47.15% articles had at least one funding source. A review of articles published in major journals allows to show how research in orthopaedics is distributed worldwide. This study shows that a variety of different journals is neccessary to reflect the broad spectrum of orthopaedics in depth. Level of Evidence III, Retrospective Comparative Study.
Tarantino, Umberto; Giai Via, Alessio; Macrì, Ernesto; Eramo, Alessandro; Marino, Valeria; Marsella, Luigi Tonino
Interest in medical errors has increased during the last few years owing to the number of medical malpractice claims. Reasons for the increasing number of claims may be related to patients' higher expectations, iatrogenic injury, and the growth of the legal services industry. Claims analysis provides helpful information in specialties in which a higher number of errors occur, highlighting areas where orthopaedic care might be improved. We determined: (1) the number of claims involving orthopaedics and traumatology in Rome; (2) the risk of litigation in elective and trauma surgery; (3) the most common surgical procedures involved in claims and indemnity payments; (4) the time between the adverse medical event and the judgment date; and (5) issues related to informed consent. We analyzed 1925 malpractice judgments decided in the Civil Court of Rome between 2004 and 2010. In total, 243 orthopaedics claims were filed, and in 75% of these cases surgeons were found liable; 149 (61%) of these resulted from elective surgery. Surgical teams were sued in 30 claims and found liable in 22. The total indemnity payment ordered was more than €12,350,000 (USD 16,190,000). THA and spinal surgery were the most common surgical procedures involved. Inadequate informed consent was reported in 5.3% of cases. Our study shows that careful medical examination, accurate documentation in medical records, and adequate informed consent might reduce the number of claims. We suggest monitoring of court judgments would be useful to develop prevention strategies to reduce claims.
Mavrogenis, Andreas F; Megaloikonomos, Panayiotis D; Panagopoulos, Georgios N; Mauffrey, Cyril; Quaile, Andrew; Scarlat, Marius M
International Orthopaedics was founded in 1977. Within the 40 volumes and 247 issues since its launch, 5462 scientific articles have been published. This article identifies, analyses and categorises the best cited articles published by the journal to date. We searched Elsevier Scopus database for citations of all papers published in International Orthopaedics since its foundation. Source title was selected, and the journal's title was introduced in the search engine. The identified articles were sorted based on their total number of received citations, forming a descending list from 1 to 100. Total citations and self-citations of all co-authors were recorded. Year of publication, number of co-authors, number of pages, country and institution of origin and study type were identified. The best 100 papers and their citations correspond approximately to 2% of all the journal's publications. Total citations ranged from 62 to 272; 26 papers had >100 citations, of which self-citations accounted for <4%. Mean authorship number per paper was four and mean page number 6.5. United States, Japan and Germany ranked the top three countries of origin. The most common study type was case series, and most common topics were adult reconstruction, sports medicine and trauma. This article identifies topics, authors and institutions that contributed with their high-quality work in the journal's development over time. International Orthopaedics remains faithful to its authors and readers by publishing topical, well-written articles in excellent English.
Wegener, Stephen T; Pollak, Andrew N; Frey, Katherine P; Hymes, Robert A; Archer, Kristin R; Jones, Clifford B; Seymour, Rachel B; OʼToole, Robert V; Castillo, Renan C; Huang, Yanjie; Scharfstein, Daniel O; MacKenzie, Ellen J
Previous research suggests that the care provided to trauma patients could be improved by including early screening and management of emotional distress and psychological comorbidity. The Trauma Collaborative Care (TCC) program, which is based on the principles of well-established models of collaborative care, was designed to address this gap in trauma center care. This article describes the TCC program and the design of a multicenter study to evaluate its effectiveness for improving patient outcomes after major, high-energy orthopaedic trauma at level 1 trauma centers. The TCC program was evaluated by comparing outcomes of patients treated at 6 intervention sites (n = 481) with 6 trauma centers where care was delivered as usual (control sites, n = 419). Compared with standard treatment alone, it is hypothesized that access to the TCC program plus standard treatment will result in lower rates of poor patient-reported function, depression, and posttraumatic stress disorder.
Greenberg, Sarah E; VanHouten, Jacob P; Lakomkin, Nikita; Ehrenfeld, Jesse; Jahangir, Amir Alex; Boyce, Robert H; Obremksey, William T; Sethi, Manish K
The aim of our study was to determine the association between admitting service, medicine or orthopaedics, and length of stay (LOS) for a geriatric hip fracture patient. Retrospective. Urban level 1 trauma center. Six hundred fourteen geriatric hip fracture patients from 2000 to 2009. Orthopaedic surgery for geriatric hip fracture. Patient demographics, medical comorbidities, hospitalization length, and admitting service. Negative binomial regression used to determine association between LOS and admitting service. Six hundred fourteen geriatric hip fracture patients were included in the analysis, of whom 49.2% of patients (n = 302) were admitted to the orthopaedic service and 50.8% (3 = 312) to the medicine service. The median LOS for patients admitted to orthopaedics was 4.5 days compared with 7 days for patients admitted to medicine (P < 0.0001). Readmission was also significantly higher for patients admitted to medicine (n = 92, 29.8%) than for those admitted to orthopaedics (n = 70, 23.1%). After controlling for important patient factors, it was determined that medicine patients are expected to stay about 1.5 times (incidence rate ratio: 1.48, P < 0.0001) longer in the hospital than orthopaedic patients. This is the largest study to demonstrate that admission to the medicine service compared with the orthopaedic service increases a geriatric hip fractures patient's expected LOS. Since LOS is a major driver of cost as well as a measure of quality care, it is important to understand the factors that lead to a longer hospital stay to better allocate hospital resources. Based on the results from our institution, orthopaedic surgeons should be aware that admission to medicine might increase a patient's expected LOS. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Bahari, Syah; Morris, Seamus; Lenehan, Brian; McElwain, John P
Fracture of the distal radius from low energy trauma is a common presentation to orthopaedic trauma services. This fragility type fracture is associated with underlying osteoporosis. Osteoporosis is a 'silent disease' where fragility fracture is a common presentation. Orthopaedic surgeons may be the only physician that these patients encounter. We found a high percentage of female patients who sustained a fragility fracture of the distal radius have an underlying osteoporosis. Further management of osteoporosis is important to prevent future fragility fractures.
Gasser, Bernhard; Tiefenboeck, Thomas M; Boesmueller, Sandra; Kivaranovic, Danijel; Bukaty, Adam; Platzer, Patrick
There is still no evidence in literature for damage control orthopaedics (DCO), early total care (ETC) or using external fixation solely in fractures of the long bones in multi-system-trauma. The aim of this study was to determine parameters influencing the choice of treatment in clinical routine (DCO, ETC, or EF) in femoral or tibial shaft fractures in combination with multi-system-trauma, severe soft tissue damage or both. Data of 236 patients with 280 fractures of long bones of the lower extremities treated at a level I trauma center were analysed. Clinical parameters on arrival (age, sex [m/f], ISS, fracture site [femur/tibia], soft tissue damage [closed or open fractures according to the Gustilo-Anderson classification], pulmonary injury [yes/no]) were collected and analysed whether they influence the choice of upcoming treatment (DCO/ETC/EF). Our findings showed that high ISS and severe soft tissue damage (grade III) significantly correlated with DCO. High ISS, old age, female sex and fracture site (tibia) correlated with EF. This group of sole use of external fixation had highest rate of complications, 69% were associated with at least one complication. Severely injured patients are treated significantly more often with DCO or EF. The presence of higher ISS (≥16) and of type III open fractures increased the use of DCO. However, ISS, fracture-site, patient's age, type III open fractures or sex (female) increased the use of EF compared to ETC.
Pretell-Mazzini, Juan; Subhawong, Ty; Hernandez, Victor H; Campo, Rafael
➤Advances in combined antiretroviral therapy (cART) in recent years have transformed HIV infection into a chronic disease when treatment is available, increasing a patient's life expectancy and the chances that orthopaedic surgeons will encounter such patients in their clinical practice.➤Musculoskeletal manifestations in patients with HIV infection are common and sometimes are the initial presentation of the disease. Knowledge about neoplasms and associated conditions affecting muscle, bones, and joints is essential for successful management.➤Since the advent of cART, total joint arthroplasty has been shown to be a safe procedure; however, perioperative infection is still a small risk in patients with uncontrolled viral loads or CD4 counts of <400 cells/mm(3).➤With regard to trauma surgery, the rates of early and late infection around implants, as well as union rates, are comparable with those in the HIV-negative population; however, there is an increased risk of pulmonary, renal, and infectious or septic complications in the polytrauma setting.➤Factors such as CD4 count, nutritional status, cART therapy, viral load count, and other comorbidities (hemophilia, infection among intravenous drug users, etc.) should be considered when treating these patients in order to optimize their clinical outcomes. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.
Grabowski, Gregory; Walker, Justin W
The pursuit of a fellowship has become increasingly popular over the past several years, with >90% of graduating orthopaedic residents applying for a fellowship position. Despite the ample literature available pertaining to the selection of orthopaedic residents, there is no similar research for the selection of fellows. Four hundred and fifteen of 475 orthopaedic fellowship program directors in the United States were surveyed on selection criteria used to choose fellows. The survey asked fellowship directors to rank the importance of various criteria on a Likert scale of 1 through 5 points (with 1 point denoting most important and 5 points denoting least important). The overall response rate was 193 (46.5%) of 415 orthopaedic fellowship program directors. The most important criteria in selecting an applicant for an interview were a letter of recommendation from subspecialty faculty (1.38 points), quality of residency program (2.02 points), and a letter of recommendation from the residency program director (2.12 points). The most important criteria in completing the rank order list following the interview were the interview (1.17 points), a letter of recommendation from subspecialty faculty (1.46 points), a letter of recommendation from the residency program director (2.16 points), and expressed interest in program (2.16 points).
Dulai, Sukhdeep K; Slobogean, Bronwyn L T; Beauchamp, Richard D; Mulpuri, Kishore
The promotion and practice of evidence-based medicine necessitates a critical evaluation of medical literature, including the criterion standard of randomized clinical trials (RCTs). Recent studies have examined the quality of RCTs in various surgical specialties, but no study has focused on pediatric orthopaedics. The purpose of this study was to assess and describe the quality of RCTs published in the last 10 years in journals with high clinical impact in pediatric orthopaedics. All of the RCTs in pediatric orthopaedics published in 5 well-recognized journals between 1995 and 2005 were reviewed using the Detsky Quality Assessment Scale. The mean percentage score on the Detsky scale was 53% (95% confidence interval, 46%-60%). Only 7 (19%) of the articles satisfied the threshold for a satisfactory level of methodological quality (Detsky >75%). Most RCTs in pediatric orthopaedics that are published in well-recognized peer-reviewed journals demonstrate substantial deficiencies in methodological quality. Particular areas of weakness include inadequate rigor and reporting of randomization methods, use of inappropriate or poorly described outcome measures, inadequate description of inclusion and exclusion criteria, and inappropriate statistical analysis. Further efforts are necessary to improve the conduct and reporting of clinical trials in this field to avoid inadvertent misinformation of the clinical community.
Marques, Evelyne GSC; Júnior, Gerson A Pereira; Neto, Bruno F Muller; Freitas, Rodrigo A; Yaegashi, Lygia B; Almeida, Carlos E Fagotti; Júnior, Jayme Adriano Farina
Victims of electrical burns account for approximately 5% of admissions to major burn centers. The first case of visceral injury caused by electrical burns was described in 1927 by Simonin, who reported perforation of the small intestine. Other rare cases were reported over the following years. The colon and small intestine were the organs most frequently affected. Less frequently involved organs were the heart, esophagus, stomach, pancreas, liver, gallbladder, lung, and kidney. We highlight the potential fatal visceral injuries after the electrical trauma. This study provides a review on this topic and proposes a management flowchart that should be adopted by the multidisciplinary team to treat these patients. Conclusion: Visceral injuries are rare in electrical burns victims, but it can be severe and are associated with high rates of morbidity and mortality, sometimes requiring a more interventional approach. PMID:24624308
This systematic review aimed to explore the effects of different degrees of parental disclosure of traumatic material from the past on the psychological well-being of children in refugee families. A majority of studies emphasize the importance of the timing of disclosure and the manner in which it takes place, rather than the effects of open communication or silencing strategies per se. A pattern emerged in which the level of parental disclosure that promotes psychological adjustment in refugee children depends on whether the children themselves have been directly exposed to traumatic experiences, and whether the children are prepubescent or older. The process of trauma disclosure is highly culturally embedded. Future research needs to address the culturally shaped variations in modulated disclosure and further explore how modulated disclosure can be facilitated in family therapy with traumatized refugee families. PMID:25656844
Dalgaard, Nina Thorup; Montgomery, Edith
This systematic review aimed to explore the effects of different degrees of parental disclosure of traumatic material from the past on the psychological well-being of children in refugee families. A majority of studies emphasize the importance of the timing of disclosure and the manner in which it takes place, rather than the effects of open communication or silencing strategies per se. A pattern emerged in which the level of parental disclosure that promotes psychological adjustment in refugee children depends on whether the children themselves have been directly exposed to traumatic experiences, and whether the children are prepubescent or older. The process of trauma disclosure is highly culturally embedded. Future research needs to address the culturally shaped variations in modulated disclosure and further explore how modulated disclosure can be facilitated in family therapy with traumatized refugee families.
Sala-Pérez, Sergi; España-Tost, Antoni; Vidal-Bel, August
Inverted ductal papilloma of the oral cavity is an infrequent benign neoplasm of papillary appearance that originates in the secretory duct of a salivary gland. The etiology is unknown, though some authors have related it to human papillomavirus (HPV) infection. We present the case of a 40-year-old woman with a tumor of the lower lip mucosa. Histopathological study of the lesion diagnosed inverted ductal papilloma of the oral cavity. Human papillomavirus DNA detection and typing based on tumor lesion DNA amplification and posterior hybridization, revealed no presence of viral DNA. The antecedents of trauma reported by the patient could have played an important role in the development of this tumor. Key words:Inverted ductal papilloma, intraductal papilloma, oral papilloma, papillary epidermoid adenoma. PMID:24455058
Saltzherr, T P; Fung Kon Jin, P H P; Beenen, L F M; Vandertop, W P; Goslings, J C
Patients with a (potential) cervical spine injury can be subdivided into low-risk and high-risk patients. With a detailed history and physical examination the cervical spine of patients in the "low-risk" group can be "cleared" without further radiographic examinations. X-ray imaging (3-view series) is currently the primary choice of imaging for patients in the "low-risk" group with a suspected cervical spine injury after blunt trauma. For patients in the "high-risk"group because of its higher sensitivity a computed tomography scan is primarily advised or, alternatively, the cervical spine is immobilised until the patient can be reliably questioned and examined again. For the imaging of traumatic soft tissue injuries of the cervical spine magnetic resonance imaging is the technique of choice.
Sala-Pérez, Sergi; España-Tost, Antoni; Vidal-Bel, August; Gay-Escoda, Cosme
Inverted ductal papilloma of the oral cavity is an infrequent benign neoplasm of papillary appearance that originates in the secretory duct of a salivary gland. The etiology is unknown, though some authors have related it to human papillomavirus (HPV) infection. We present the case of a 40-year-old woman with a tumor of the lower lip mucosa. Histopathological study of the lesion diagnosed inverted ductal papilloma of the oral cavity. Human papillomavirus DNA detection and typing based on tumor lesion DNA amplification and posterior hybridization, revealed no presence of viral DNA. The antecedents of trauma reported by the patient could have played an important role in the development of this tumor. Key words:Inverted ductal papilloma, intraductal papilloma, oral papilloma, papillary epidermoid adenoma.
Sankar, Wudbhav N; Weiss, Jennifer; Skaggs, David L
The occasional consultation on a neonate can be unfamiliar territory for many orthopaedic surgeons. Just as children are not little adults, newborns are not just little children; rather, they have a unique physiology that affects the presentation of their orthopaedic concerns. Careful physical examination with appropriate understanding of neonatal development is essential to making the proper diagnosis. A flail extremity in the newborn is most commonly attributed to fracture or brachial plexus palsy; however, infection must also be considered and ruled out to prevent long-term morbidity. Metatarsus adductus is the most common foot abnormality, but clubfoot, calcaneovalgus deformity, and congenital vertical talus may also be encountered. Joint contractures that spontaneously improve are normal in the newborn, but it is important to identify and institute proper treatment for early developmental dysplasia of the hip, congenital knee dislocation, and torticollis. Clavicular pseudarthrosis and periosteal reactions may be discovered on radiographic examination. A basic understanding of the relevant conditions will help the orthopaedist with the initial diagnosis and management of orthopaedic issues in the newborn.
Barr, Joseph S; McCaslin, Michael J; Hinds, Cynthia K
The word retirement is going out of fashion. Many orthopaedic surgeons want to work in some capacity when they stop performing surgery. Making a smooth transition from a busy orthopaedic practice to alternative work demands advanced planning. The surgeon must consider personal issues that involve how to use human capital (his or her accumulated knowledge and experience). New ventures, hobbies, travel, and spending time with family and friends are some possibilities. Plans for slowing down or leaving the practice should be discussed and agreed on well ahead of time. Agreements for buyouts may be difficult to work out and will require creative thinking. The solo practitioner can close the practice or hire a successor. Financial planning is perhaps the most important consideration and should be started by approximately age 40. It is recommended that the surgeon develop a portfolio of secure investments and annuities to provide adequate income for as long as is needed and then to turn the residual income to one's family, favorite charities, or other desired cause. A team of competent advisors is needed to help develop and achieve one's goals, create financial security, and provide the discipline to carry out the needed planning for life after orthopaedics.
Ramasamy, Arul; Eardley, W G P; Edwards, D S; Clasper, J C; Stewart, M P M
The First World War (1914-1918) was the first truly industrial conflict in human history. Never before had rifle fire and artillery barrage been employed on a global scale. It was a conflict that over 4 years would leave over 750,000 British troops dead with a further 1.6 million injured, the majority with orthopaedic injuries. Against this backdrop, the skills of the orthopaedic surgeon were brought to the fore. Many of those techniques and systems form the foundation of modern orthopaedic trauma management. On the centenary of 'the War to end all Wars', we review the significant advances in wound management, fracture treatment, nerve injury and rehabilitation that were developed during that conflict. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Kyriopoulos, E.J.; Kyriakopoulos, A.; Karonidis, A.; Gravvanis, A.; Gamatsi, I.; Tsironis, C.; Tsoutsos, D.
Summary Mucor fungus infection is a rare opportunistic infection, rapidly progressive and often fatal in immunocompromised patients, or in patients with chronic debilitating diseases. We report six cases of trauma patients with mucormycosis. Three had severe thermal burns, one of them with a medical history of diabetes mellitus. The other three patients suffered from severe soft tissue injuries caused by traffic accidents. In all cases there had been spontaneous exposure and contact of the wounds with soil. During hospitalization, fungi cultures and/or biopsies of all wounds were performed and all resulted positive. The patients were treated with Amphotericin B (AmB) and surgical debridement. Two of them died and the other four were fully healed and discharged. Mucormycosis should be considered in any case of aggressive skin tissue necrosis with a history of soiled wounds. We suggest that mucormycosis is treated by intravenous and local administration of AmB, extensive and repeated debridement and cautious coverage of the wound. The plastic surgeon must wait for negative swab cultures and biopsies before covering the defects with skin grafts or flaps. Reconstruction may be challenging, depending on the extent, depth, location and special indications of the affected site and the donor site availability. PMID:27777549
Kyriopoulos, E J; Kyriakopoulos, A; Karonidis, A; Gravvanis, A; Gamatsi, I; Tsironis, C; Tsoutsos, D
Mucor fungus infection is a rare opportunistic infection, rapidly progressive and often fatal in immunocompromised patients, or in patients with chronic debilitating diseases. We report six cases of trauma patients with mucormycosis. Three had severe thermal burns, one of them with a medical history of diabetes mellitus. The other three patients suffered from severe soft tissue injuries caused by traffic accidents. In all cases there had been spontaneous exposure and contact of the wounds with soil. During hospitalization, fungi cultures and/or biopsies of all wounds were performed and all resulted positive. The patients were treated with Amphotericin B (AmB) and surgical debridement. Two of them died and the other four were fully healed and discharged. Mucormycosis should be considered in any case of aggressive skin tissue necrosis with a history of soiled wounds. We suggest that mucormycosis is treated by intravenous and local administration of AmB, extensive and repeated debridement and cautious coverage of the wound. The plastic surgeon must wait for negative swab cultures and biopsies before covering the defects with skin grafts or flaps. Reconstruction may be challenging, depending on the extent, depth, location and special indications of the affected site and the donor site availability.
Wilson, Allyson; Hutchinson, Marie; Hurley, John
Trauma-informed care (TIC) is increasingly recognized as an approach to improving consumers' experience of, and outcomes from, mental health services. Deriving consensus on the definition, successful approaches, and consumer experiences of TIC is yet to be attained. In the present study, we sought to clarify the challenges experienced by mental health nurses in embedding TIC into acute inpatient settings within Australia. A systematic search of electronic databases was undertaken to identify primary research conducted on the topic of TIC. A narrative review and synthesis of the 11 manuscripts retained from the search was performed. The main findings from the review indicate that there are very few studies focussing on TIC in the Australian context of acute mental health care. The review demonstrates that TIC can support a positive organizational culture and improve consumer experiences of care. The present review highlights that there is an urgency for mental health nurses to identify their role in delivering and evaluating TIC, inclusive of undertaking training and clinical supervision, and to engage in systemic efforts to change service cultures. © 2017 Australian College of Mental Health Nurses Inc.
Olson, Steven A; Mather, Richard C
Orthopaedic surgery practices can provide substantial value to healthcare systems. Increasingly, healthcare administrators are speaking of the need for alignment between physicians and healthcare systems. However, physicians often do not understand what healthcare administrators value and therefore have difficulty articulating the value they create in discussions with their hospital or healthcare organization. Many health systems and hospitals use service lines as an organizational structure to track the relevant data and manage the resources associated with a particular type of care, such as musculoskeletal care. Understanding service lines and their management can be useful for orthopaedic surgeons interested in interacting with their hospital systems. We provide an overview of two basic types of value orthopaedic surgeons create for healthcare systems: financial or volume-driven benefits and nonfinancial quality or value-driven patient care benefits. We performed a search of PubMed from 1965 to 2012 using the term "service line." Of the 351 citations identified, 18 citations specifically involved the use of service lines to improve patient care in both nursing and medical journals. A service line is a structure used in healthcare organizations to enable management of a subset of activities or resources in a focused area of patient care delivery. There is not a consistent definition of what resources are managed within a service line from hospital to hospital. Physicians can positively impact patient care through engaging in service line management. There is increasing pressure for healthcare systems and hospitals to partner with orthopaedic surgeons. The peer-reviewed literature demonstrates there are limited resources for physicians to understand the value they create when attempting to negotiate with their hospital or healthcare organization. To effectively negotiate for resources to provide the best care for patients, orthopaedic surgeons need to claim and
Lander, Sarah T; Sanders, James O; Cook, Peter C; O'Malley, Natasha T
Internet searches and social media utilization in health care has exploded over the past 5 years, and patients utilize it to gain information on their health conditions and physicians. Social media has the potential to serve as a means for education, communication, and marketing in all health care specialties. Physicians are sometimes reluctant to engage because of concerns of privacy, litigation, and lack of experience with this modality. Many surgical subspecialties have capitalized on social media but no study to date has examined the specific footprint of pediatric orthopaedic surgeons in this realm. We aim to quantify the utilization of individual social media platforms by pediatric orthopaedic surgeons, and identify any differences between private and hospital-based physicians, but also regional differences. Using the Pediatric Orthopaedic Society of North America Member Directory, each active member's social media presence was reviewed through an Internet search. Members were stratified on the basis of practice model and geographic location. Individual Internet searches, social media sites, and number of publications were reviewed for social media presence. Of 987 Pediatric Orthopaedic Society of North America members, 95% had a professional webpage, 14.8% a professional Facebook page, 2.2% a professional Twitter page, 36.8% a LinkedIn profile, 25.8% a ResearchGate profile, 33% at least 1 YouTube. Hospital-based physicians had a lower mean level of utilization of social media compared with their private practice peers, and a higher incidence of Pubmed publications. Private practice physicians had double the social media utilization. Regional differences reveal that practicing Pediatric Orthopaedists in the Northeast had increased utilization of ResearchGate and LinkedIn and the West had the lowest mean social media utilization levels. The rapid expansion of social media usage by patients and their family members is an undeniable force affecting the health
Turkelson, Charles; Jacobs, Joshua J
A technology assessment is a literature-based research project that seeks to determine whether a medical device, drug, procedure, or biologic is effective or to summarize literature on a given technology. A well-conducted assessment is a form of secondary research that employs the same steps used in primary research studies (ie, well-designed clinical trials). The primary difference is that in technology assessment the investigator does not collect the raw data. Rather, (s)he must use data collected by someone else. Nevertheless, a well-designed assessment, like a well-designed study, employs the scientific method, which is a method designed to combat bias. When there is little available information, such as with new technologies, unbiased examinations can typically show that enthusiasm for that technology is not backed by much data. When there is more information, assessments can not only determine whether a technology is effective, but also how effective it is. Technology assessments can provide busy orthopaedic surgeons (who do not have the time to keep up with and critically evaluate current literature) with succinct information that enables them to rapidly determine what is and what is not known about any given medical technology.
reticulated foam, an occlusive semipermeable dressing, and a suction device with a fluid re- ceptacle (Figure 1). Several commer- cially available NPWT systems...Semiocclusive Dressing Adhesive drapes are required to seal the wound to allow production of an effective vacuum. Semiocclusive membranes are used to avoid...protein loss and wound desiccation while isolating the wound from nosoco- mial contaminants. Most manufac- turers provide precut adhesive poly- urethane
was inversely correlated with traumatic brain injury. Injury severity score, ventilator days, ICU days and total hospital days positively correlated...Vitamin D receptor 27. BMP2 28. BMP4 29. Sclerostin 30. Frizzled 9 31. FOXO1 32. FOXO3 3. Radiographs for these individuals have been examined for HO...Coma Scale (GCS) which is a more specific indicator of traumatic brain injury. The GCS on admission has inaccuracies due to intubation and medication
have now examined 1095 patients over a two year period for HO and single nucleotide polymorphisms that may be associated with HO. Certain...all patients using the PUREGENE system (Gentra Systems Inc., Minneapolis, MN). Sixty one single nucleotide polymorphisms were examined including...lung cancer and cigarette smoke, there is also evidence of genetic predisposition to common skeletal diseases such as osteoporosis .13,14 We are
patients including: o ISS o Head AIS o Number ICU days o Ventilator Days o Ventilator Assisted Pneumonia o Age o Race o Gender • Manuscript submitted to...injury scores are included in ISS and both may be associated with ICU and ventilator days. Gender was associated with risk with female gender actually...radiographic findings of HO in the same cohort. Statistical analyses were performed to determine associations between ISS, head AIS, ICU days, days on
The advantages of flat panel detector technology with X-ray sensitive semiconductor technology has increasingly gained acceptance in the inpatient setting for diagnostic X-ray imaging in recent years and has replaced conventional X-ray films. For intraoperative imaging C-arms, not least for cost reasons, are still based on conventional image intensifier technology. By improving the robustness of the flat panel technology and cost-effective production, future spread of these technologies in the OR could be expected. Direct digital imaging with improved image quality, with a possible reduction in radiation dose while at the same time enlarging the image field, can affect the procedural quality of surgery. A return on investment can be achieved in part by saving time and avoiding additional postoperative imaging.
V, Dei Giudici; N, Giampaolini; A, Panfighi; M, Marinelli; R, Procaccini; A, Gigante
The main concern for orthopaedic treatment in polytrauma has always been the same for almost forty years, which also regards “where” and “when” to proceed; correct surgical timing and correct interpretation of the DCO concept are still being debated. In the last few years, several attempts have been made to classify patients based on their clinical presentation and by trying to figure out which vital parameters are able to predict the patient’s outcome. This study evaluated all patients who presented with code red at the Emergency Department of our Hospital, a level II trauma center. For every patient, the following characteristics were noted: sex, age, day of hospitalization, orthopaedic trauma, time to surgery, presence of an associated surgical condition in the fields of general surgery, thoracic surgery, neurosurgery and vascular surgery, cardiac frequency, blood pressure, oxygen saturation, Glasgow Coma Scale and laboratory data. All patients included were divided into subgroups based on orthopaedic surgical timing. Two other subgroups were also identified and analyzed in detail: deceased and weekend traumas. A total of 208 patients were included. Our primary goal was to identify a correlation between the mortality and surgical timing of the orthopaedic procedures; our secondary goal was to recognize, if present, a statistically relevant association between historical, clinical and laboratory data, and mortality rate, defining any possible risk factor. A correlation between mortality and orthopaedic surgical timing was not found. Analyzing laboratory data revealed an interesting correlation between mortality and: blood pressure, platelet count, cardiac frequency, hematocrit, hemoglobin and age. PMID:26312113
Bruinsma, Wendy E; Becker, Stéphanie J E; Guitton, Thierry G; Kadzielski, John; Ring, David
So-called "hazardous attitudes" (macho, impulsive, antiauthority, resignation, invulnerable, and confident) were identified by the Federal Aviation Administration and the Canadian Air Transport Administration as contributing to road traffic incidents among college-aged drivers and felt to be useful for the prevention of aviation accidents. The concept of hazardous attitudes may also be useful in understanding adverse events in surgery, but it has not been widely studied. We surveyed a cohort of orthopaedic surgeons to determine the following: (1) What is the prevalence of hazardous attitudes in a large cohort of orthopaedic surgeons? (2) Do practice setting and/or demographics influence variation in hazardous attitudes in our cohort of surgeons? (3) Do surgeons feel they work in a climate that promotes patient safety? We asked the members of the Science of Variation Group-fully trained, practicing orthopaedic and trauma surgeons from around the world-to complete a questionnaire validated in college-aged drivers measuring six attitudes associated with a greater likelihood of collision and used by pilots to assess and teach aviation safety. We accepted this validation as applicable to surgeons and modified the questionnaire accordingly. We also asked them to complete the Modified Safety Climate Questionnaire, a questionnaire assessing the absence of a safety climate that is based on the patient safety cultures in healthcare organizations instrument. Three hundred sixty-four orthopaedic surgeons participated, representing a 47% response rate of those with correct email addresses who were invited. Thirty-eight percent (137 of 364 surgeons) had at least one score that would have been considered dangerously high in pilots (> 20), including 102 with dangerous levels of macho (28%) and 41 with dangerous levels of self-confidence (11%). After accounting for possible confounding variables, the variables most closely associated with a macho attitude deemed hazardous in pilots
Green, Katherine; And Others
GRADES OR AGES: K-12. SUBJECT MATTER: Literature. ORGANIZATION AND PHYSICAL APPEARANCE: The guide starts with an overview of literature topics for grades 4-12, followed by suggested activities, a list of supplementary books for elementary grades, and a table listing specific skills. The remainder of the guide deals with ten cardinal concerns and…
Verner, Zenobia, Ed.
This issue provides a selection of articles about literature and the teaching of literature. Titles include "Sin, Salvation, and Grace in 'The Scarlet Letter,'""'The Road Not Taken': A Study in Ambiguity,""In Search of Shakespeare: The Essential Years,""Right Deeds for Wrong Reasons: Teaching the Bible as…
Cheriachan, Deepak; Hughes, Adrian M; du Moulin, William S M; Williams, Christopher; Molnar, Robert
To evaluate the ionizing radiation dose received by the eyes of orthopaedic surgeons during various orthopaedic procedures. Secondary objective was to compare the ionizing radiation dose received between differing experience level. Prospective comparative study between January 2013 and May 2014. Westmead Hospital, a Level 1 Trauma Centre for Greater Western Sydney. A total of 26 surgeons volunteered to participate within the study. Experience level, procedure performed, fluoroscopy time, dose area product, total air kerma, and eye dose received was recorded. Participants were evaluated on procedure and experience level. Radiation dose received at eye level by the primary surgeon during an orthopaedic procedure. Data from a total of 131 cases was recorded and included for analysis. The mean radiation dose detected at the eye level of the primary surgeon was 0.02 mSv (SD = 0.05 mSv) per procedure. Radiation at eye level was only detected in 31 of the 131 cases. The highest registered dose for a single procedure was 0.31 mSv. Femoral nails and pelvic fixation procedures had a significantly higher mean dose received than other procedure groups (0.04 mSv (SD = 0.07 mSv) and 0.04 mSv (SD = 0.06 mSv), respectively). Comparing the eye doses received by orthopaedic consultants and trainees, there was no significant difference between the 2 groups. The risk of harmful levels of radiation exposure at eye level to orthopaedic surgeons is low. This risk is greatest during insertion of femoral intramedullary nails and pelvic fixation, and it is recommended that in these situations, surgeons take all reasonable precautions to minimize radiation dose. The orthopaedic trainees in this study were not subjected to higher doses of radiation than their consultant trainers. On the basis of these results, most of the orthopaedic surgeons remain well below the yearly radiation dose of 20 mSv as recommended by the International Commission on Radiological Protection.
From a fishing village with colonial surgeons from the East India Company, Singapore is now a medical and business hub servicing the region and beyond in trade and medical education. Orthopaedic Surgery is a young specialty and is the fastest growing sub-specialty in Surgery. Orthopaedic education in Singapore has a structured syllabus and training is coordinated with the Royal Colleges and the American Academy of Orthopaedic Surgeons. Part of the training as Fellows is in the United Kingdom and USA on an HMDP Fellowship. Ethics and Continuing Medical Education need further emphasis. Sub-specialisation in Orthopaedic Surgery is now well-established in Trauma, Adult Reconstructive Surgery, Sports Medicine, Spinal Surgery, Hand Surgery and Rehabilitation Medicine. Ageing in the next millennium with osteoporosis and hip fracture problems of gait and balance need more orthopaedic surgeons to be committed to rehabilitation medicine and voluntary service in the community. There is a need for good role models and knowledge on Quality Assurance, Clinical Pathways and Administration. Appropriate use of high technology and care for the aged in the community with dignity is fundamental to good ethical practice. Selfish, pecuniary interests will destroy the very soul and fabric of medicine.
Background Musculoskeletal complaints are probably the most frequent reasons for visiting a doctor. They comprise more than a quarter of the complaints to primary practitioners and are also the most common reason for referral to secondary or tertiary medicine. The clinicians most frequently consulted on musculoskeletal problems, and probably perceived to know most on the topic are orthopaedic surgeons. But in Israel, there is significant ambivalence with various aspects of the consultations provided by orthopaedic surgeons, both among the public and among various groups of clinicians, particularly family practitioners and physiotherapists. Methods In order to understand this problem we integrate new data we have collected with previously published data. New data include the rates of visits to orthopaedic surgeons per annum in one of Israel’s large non-profit HMO’s, and the domains of the visits to an orthopaedic surgeon. Results Orthopaedic surgeons are the third most frequently contracted secondary specialists in one of the Israeli HMO’s. Between 2009 and 2012 there was a 1.7% increase in visits to orthopaedists per annum (P < 0.0001, after correction for population growth). Almost 80% of the domains of the problems presented to an orthopaedic surgeon were in fields orthopaedic surgeons have limited formal training. Discussion While orthopaedic surgeons are clearly the authority on surgical problems of the musculoskeletal system, most musculoskeletal problems are not surgical, and the orthopaedic surgeon often lacks training in these areas which might be termed orthopaedic medicine. Furthermore, in Israel and in many other developed countries there is no accessible medical specialty that studies these problems, trains medical students in the subject and focuses on treating these problems. The neglect of this area which can be called the “Orthopaedic Medicine Lacuna” is responsible for inadequate treatment of non-surgical problems of the
Kellam, James F; Archibald, Douglas; Barber, James W; Christian, Eugene P; D'Ascoli, Richard J; Haynes, Richard J; Hecht, Suzanne S; Hurwitz, Shepard R; Kellam, James F; McLaren, Alexander C; Peabody, Terrance D; Southworth, Stephen R; Strauss, Robert W; Wadey, Veronica M R
With the changing delivery of orthopaedic surgical care, there is a need to define the knowledge and competencies that are expected of an orthopaedist providing general and/or acute orthopaedic care. This article provides a proposal for the knowledge and competencies needed for an orthopaedist to practice general and/or acute care orthopaedic surgery. Using the modified Delphi method, the General Orthopaedic Competency Task Force consisting of stakeholders associated with general orthopaedic practice has proposed the core knowledge and competencies that should be maintained by orthopaedists who practice emergency and general orthopaedic surgery. For relevancy to clinical practice, 2 basic sets of competencies were established. The assessment competencies pertain to the general knowledge needed to evaluate, investigate, and determine an overall management plan. The management competencies are generally procedural in nature and are divided into 2 groups. For the Management 1 group, the orthopaedist should be competent to provide definitive care including assessment, investigation, initial or emergency care, operative or nonoperative care, and follow-up. For the Management 2 group, the orthopaedist should be competent to assess, investigate, and commence timely non-emergency or emergency care and then either transfer the patient to the appropriate subspecialist's care or provide definitive care based on the urgency of care, exceptional practice circumstance, or individual's higher training. This may include some higher-level procedures usually performed by a subspecialist, but are consistent with one's practice based on experience, practice environment, and/or specialty interest. These competencies are the first step in defining the practice of general orthopaedic surgery including acute orthopaedic care. Further validation and discussion among educators, general orthopaedic surgeons, and subspecialists will ensure that these are relevant to clinical practice. These
Wurth, Gene R; Sherr, Judy H; Coffman, Thomas M
Members of orthopaedic industry commit a significant amount of funds each year to support research and education programs that are directly related to their product(s). In addition, industry supports organizations such as the Orthopaedic Research and Education Foundation. The relationship between the Orthopaedic Research and Education Foundation and industry began in the early 1980s. The support to the Orthopaedic Research and Education Foundation from industry primarily has come in the form of unrestricted grants. These grants best can be looked at as an investment rather than a contribution. This form of giving, once called corporate philanthropy is more accurately referred to as strategic philanthropy. Members of industry make these investments to enhance their reputations, build brand awareness, market their products and services, improve employee morale, increase customer loyalty, and establish strategic alliances. The specialty of orthopaedics is among the leaders in medicine in the amount of funding raised within the specialty for research and education programs. This is because of the amount of support from members of industry and the surgeons. During the past 15 years, 40% of the annual support to the Orthopaedic Research and Education Foundation has come from industry and the balance has come from surgeons and members of lay public. Future industry support of the Orthopaedic Research and Education Foundation and other organizations within the specialty of orthopaedics will be dependent on the continued demonstration of tangible returns in areas described.
Mediouni, Mohamed; Volosnikov, Alexander
Generally, in some universities of medicine, orthopaedic training procedures represent a difficult task due to the inadequacies of the systems, the resources, and the use of technologies. This article explains the challenges and the needs for more research in the issue of orthopaedic simulation around the world. PMID:26566328
Hall, Kelly E; Sharp, Claire R; Adams, Cynthia R; Beilman, Gregory
In human trauma patients, most deaths result from hemorrhage and brain injury, whereas late deaths, although rare, are the result of multiple organ failure and sepsis. A variety of experimental animal models have been developed to investigate the pathophysiology of traumatic injury and evaluate novel interventions. Similar to other experimental models, these trauma models cannot recapitulate conditions of naturally occurring trauma, and therefore therapeutic interventions based on these models are often ineffective. Pet dogs with naturally occurring traumatic injury represent a promising translational model for human trauma that could be used to assess novel therapies. The purpose of this article was to review the naturally occurring canine trauma literature to highlight the similarities between canine and human trauma. The American College of Veterinary Emergency and Critical Care Veterinary Committee on Trauma has initiated the establishment of a national network of veterinary trauma centers to enhance uniform delivery of care to canine trauma patients. In addition, the Spontaneous Trauma in Animals Team, a multidisciplinary, multicenter group of researchers has created a clinical research infrastructure for carrying out large-scale clinical trials in canine trauma patients. Moving forward, these national resources can be utilized to facilitate multicenter prospective studies of canine trauma to evaluate therapies and interventions that have shown promise in experimental animal models, thus closing the critical gap in the translation of knowledge from experimental models to humans and increasing the likelihood of success in phases 1 and 2 human clinical trials.
Bus, Sicco A
In people with diabetes mellitus, foot ulcers are a major problem because they increase the risk of a foot infection and amputation and reduce quality of life. After a foot ulcer has healed, the risk of recurrence is high. Orthopaedic shoes and orthotics are often prescribed to high risk patients and aim to reduce the mechanical pressure on the plantar surface of the foot. Orthopaedic footwear that is modified to reduce pressure is not much more effective in preventing foot ulcer recurrence than orthopaedic footwear that did not undergo such modification, unless the shoes are worn as recommended. In that case, the risk of ulcer recurrence is reduced by 46%. In patients with a history of ulceration, compliance in wearing orthopaedic shoes at home is low, while these patients walk more inside the house than outside the house. Foot pressure measurements should be part of the prescription and evaluation of orthopaedic footwear for patients at high risk for foot ulceration.
Buraimoh, M. Ayodele; Liu, Jane Z.; Sundberg, Stephen B.; Mott, Michael P.
Abstract Every day surgeons call for instruments devised by surgeon trailblazers. This article aims to give an account of commonly used eponymous instruments in orthopaedic surgery, focusing on the original intent of their designers in order to inform how we use them today. We searched PubMed, the archives of longstanding medical journals, Google, the Internet Archive, and the HathiTrust Digital Library for information regarding the inventors and the developments of 7 instruments: the Steinmann pin, Bovie electrocautery, Metzenbaum scissors, Freer elevator, Cobb periosteal elevator, Kocher clamp, and Verbrugge bone holding forceps. A combination of ingenuity, necessity, circumstance and collaboration produced the inventions of the surgical tools numbered in our review. In some cases, surgical instruments were improvements of already existing technologies. The indications and applications of the orthopaedic devices have changed little. Meanwhile, instruments originally developed for other specialties have been adapted for our use. Although some argue for a transition from eponymous to descriptive terms in medicine, there is value in recognizing those who revolutionized surgical techniques and instrumentation. Through history, we have an opportunity to be inspired and to better understand our tools. PMID:28852360
Motlagh, Leila Tafreshi; Yahya, Wan Roselezam Wan
Toni Morrison is an acknowledged master of trauma literature, however trauma theory and a gender response to trauma remain largely unaccounted for her migration literature, specifically "Jazz" (1992). In her novel, two migrant women are affected by the same trauma, a crime of passion. But they choose different reactions and coping…
Benglis, David M; Sandberg, David I
Cervicomedullary compression at the foramen magnum in patients with achondroplasia can be associated with apnea, neurological deficits, and sudden death. Decompressive operations are often performed in symptomatic patients. In asymptomatic patients, the indications for prophylactic decompression are controversial. The authors present the case of a previously neurologically intact 4-month-old girl with achondroplasia who presented with severe hemiparesis after a low-velocity motor vehicle accident. Imaging studies demonstrated osseous compression of the medulla and upper cervical spinal cord with associated parenchymal signal changes. To the authors' knowledge this is the first reported case of a new neurological deficit after a minor trauma in this patient population. The authors review the relevant literature, focusing on the indications for cervicomedullary decompression in infants with achondroplasia. They propose that asymptomatic patients with achondroplasia and osseous compression at the foramen magnum should be offered prophy-lactic surgery if T2-weighted magnetic resonance imaging signal changes in the spinal cord are observed. Prophylactic surgery can be considered an option in patients whose imaging studies do not show signal changes in the spinal cord but demonstrate significant osseous compression and absence of visible subarachnoid spaces.
Bula-Sternberg, J; Laniado, M; Kittner, T; Bonnaire, F; Lein, T; Bula, P
Penetrating gunshot injuries to the head and brain are rare in Germany and the rest of Western Europe. Due to the small number of cases over here no consistent diagnostic and therapeutic standards exist in this respect. Thus these kinds of injuries present a great challenge to the attending physicians. Most of these violations are a result of a suicidal attempt or an accident. Beside violations by firearms also penetrating injuries to the head and brain due to captive bolt devices, as used in slaughtery business for the "humane" killing of animals, occur from time to time. The impact on the head differs from that caused by firearms because no projectile is leaving the barrel and the used bolt, as a fix part of the device, does not remain in the affected tissue. That implies characteristic results within the radiological imaging that might be pathbreaking for the further treatment, because the origin of such a head injury is often unknown during primary care. Consequently the knowledge of these specific findings is central to the radiologist to make the appropriate diagnosis. Based on some clinical examples the trauma-related CT-findings are introduced and a short overview of the relevant literature is also given.
Eagles, Kylee; Fralich, Laura; Stevenson, J Herbert
Understanding basic ear anatomy and function allows an examiner to quickly and accurately identify at-risk structures in patients with head and ear trauma. External ear trauma (ie, hematoma or laceration) should be promptly treated with appropriate injury-specific techniques. Tympanic membrane injuries have multiple mechanisms and can often be conservatively treated. Temporal bone fractures are a common cause of ear trauma and can be life threatening. Facial nerve injuries and hearing loss can occur in ear trauma.
Mathieu, Laurent; Joly, Benjamin; Bonnet, Stéphane; Bertani, Antoine; Rongiéras, Frédéric; Pons, François; Rigal, Sylvain
Improved survival of combat casualties in modern conflicts is especially due to early access to damage control resuscitation and surgery in forward surgical facilities. In the French Army, these small mobile units are staffed with one general surgeon and one orthopaedic surgeon who must be able to perform any kind of trauma or non trauma emergency surgery. This concept of forward surgery requires a solid foundation in general surgery which is no longer provided by the current surgical programs due to an early specialization of the residents. Obviously a specific training is needed in war trauma due to the special pathology and practice, but also in humanitarian care which is often provided in military field facilities. To meet that demand the French Military Health Service Academy created an Advanced Course for Deployment Surgery (ACDS), also called CACHIRMEX (Cours Avancé de CHIRurgie en Mission EXtérieure). Since 2007 this course is mandatory for young military surgeons before their first deployment. Orthopaedic trainees are particularly interested in learning war damage control orthopaedic tactics, general surgery life-saving procedures and humanitarian orthopaedic surgery principles in austere environments. Additional pre-deployment training was recently developed to improve the preparation of mobile surgical teams, as well as a continuing medical education for any active-duty or reserve surgeon to be deployed.
Berumen, Edmundo; Barllow, Fidel Dobarganes; Fong, Fransisco Javier; Lopez, Jorge Arturo
The advance of today's medicine could be linked very closely to the history of computers through the last twenty years. In the beginning the first attempt to build a computer was trying to help us with mathematical calculations. This has changed recently and computers are now linked to x-ray machines, CT scanners, and MRIs. Being able to share information is one of the goals of the future. Today's computer technology has helped a great deal to allow orthopaedic surgeons from around the world to consult on a difficult case or to become a part of a large database. Obtaining the results from a method of treatment using a multicentric information study can be done on a regular basis. In the future, computers will help us to retrieve information from patients' clinical history directly from a hospital database or by portable memory cards that will carry every radiograph or video from previous surgeries.
Foldager, Casper B; Bendtsen, Michael; Berg, Lise C; Brinchmann, Jan E; Brittberg, Mats; Bunger, Cody; Canseco, Jose; Chen, Li; Christensen, Bjørn B; Colombier, Pauline; Deleuran, Bent W; Edwards, James; Elmengaard, Brian; Farr, Jack; Gatenholm, Birgitta; Gomoll, Andreas H; Hui, James H; Jakobsen, Rune B; Joergensen, Natasja L; Kassem, Moustapha; Koch, Thomas; Kold, Søren; Krogsgaard, Michael R; Lauridsen, Henrik; Le, Dang; Le Visage, Catherine; Lind, Martin; Nygaard, Jens V; Olesen, Morten L; Pedersen, Michael; Rathcke, Martin; Richardson, James B; Roberts, Sally; Rölfing, Jan H D; Sakai, Daisuke; Toh, Wei Seong; Urban, Jill; Spector, Myron
The combination of modern interventional and preventive medicine has led to an epidemic of ageing. While this phenomenon is a positive consequence of an improved lifestyle and achievements in a society, the longer life expectancy is often accompanied by decline in quality of life due to musculoskeletal pain and disability. The Aarhus Regenerative Orthopaedics Symposium (AROS) 2015 was motivated by the need to address regenerative challenges in an ageing population by engaging clinicians, basic scientists, and engineers. In this position paper, we review our contemporary understanding of societal, patient-related, and basic science-related challenges in order to provide a reasoned roadmap for the future to deal with this compelling and urgent healthcare problem. PMID:28271925
Buckwalter, Joseph A
Strong traditions of basic research, clinical innovation, teaching and integrating science and evaluation of outcomes into clinical practice have characterized University of Iowa orthopaedics for ninety years. These traditions were brought to Iowa City from Vienna when Iowa City was a town of fewer than 10,000 people in a sparsely populated rural state. In the last third of the 19th century, surgeons at the University of Vienna, led by Theodore Billroth (1829-1894), helped transform the practice of surgery. They developed new more effective procedures, analyzed the results of their operations, promoted the emergence and growth of surgical specialties and sought understanding of tissue structure, physiology and pathophysiology. Their efforts made Vienna one of the world's most respected centers for operative treatment, basic and clinical research and surgical education. Two individuals who followed Billroth, Eduard Albert (1841-1900) and Adolf Lorenz (1854-1946) focused their research and clinical practice on orthopaedics. Their successes in the study and treatment of musculoskeletal disorders led one of their students, Arthur Steindler (1878-1959), a 1902 graduate of the Vienna Medical School, to pursue a career in orthopaedics. Following medical school, he worked in Lorenz's orthopaedic clinic until 1907 when he joined John Ridlon (1852-1936) at the Chicago Home for Crippled Children. In 1910, Steindler became Professor of Orthopaedics at the Drake Medical School in Des Moines, Iowa, and, in 1913, John G. Bowman, the President of the University of Iowa, recruited him to establish an orthopaedic clinical and academic program in Iowa City. For the next third of a century he guided the development of the University of Iowa Orthopaedics Department, helped establish the fields of orthopaedic biomechanics and kinesiology and tirelessly stressed the importance of physiology, pathology and assessment of the outcomes of operations. From the legacy of Billroth, Albert and
Porter, Scott E; Jobin, Charles M; Lynch, T Sean; Levine, William N
The process of matching into an orthopaedic surgery residency program can be daunting for medical students. Rumors, innuendo, urban myths, and electronic misinformation can accentuate the angst experienced by students both domestically and internationally. This article dispels myths and presents an up-to-date, evidence-based (where possible), and experience-laden road map to assist medical students interested in pursuing a career in orthopaedic surgery. Our framework takes into account the program selection, test scores, letters of recommendation, visiting rotations, interviews, and communication. We hope that this survival guide will serve as a reference point assisting medical students in achieving successful matches into orthopaedic surgery residency programs.
Goldsmith, Rachel E; Martin, Christina Gamache; Smith, Carly Parnitzke
Substantial theoretical, empirical, and clinical work examines trauma as it relates to individual victims and perpetrators. As trauma professionals, it is necessary to acknowledge facets of institutions, cultures, and communities that contribute to trauma and subsequent outcomes. Systemic trauma-contextual features of environments and institutions that give rise to trauma, maintain it, and impact posttraumatic responses-provides a framework for considering the full range of traumatic phenomena. The current issue of the Journal of Trauma & Dissociation is composed of articles that incorporate systemic approaches to trauma. This perspective extends conceptualizations of trauma to consider the influence of environments such as schools and universities, churches and other religious institutions, the military, workplace settings, hospitals, jails, and prisons; agencies and systems such as police, foster care, immigration, federal assistance, disaster management, and the media; conflicts involving war, torture, terrorism, and refugees; dynamics of racism, sexism, discrimination, bullying, and homophobia; and issues pertaining to conceptualizations, measurement, methodology, teaching, and intervention. Although it may be challenging to expand psychological and psychiatric paradigms of trauma, a systemic trauma perspective is necessary on both scientific and ethical grounds. Furthermore, a systemic trauma perspective reflects current approaches in the fields of global health, nursing, social work, and human rights. Empirical investigations and intervention science informed by this paradigm have the potential to advance scientific inquiry, lower the incidence of a broader range of traumatic experiences, and help to alleviate personal and societal suffering.
Greenberg, Sarah E.; VanHouten, Jacob P.; Lakomkin, Nikita; Ehrenfeld, Jesse; Jahangir, Amir Alex; Boyce, Robert H.; Obremksey, William T.; Sethi, Manish K.
Objectives The aim of our study was to determine the association between admitting service, medicine or orthopaedics, and length of stay (LOS) for a geriatric hip fracture patient. Design Retrospective. Setting Urban level 1 trauma center. Patients/Participants Six hundred fourteen geriatric hip fracture patients from 2000 to 2009. Interventions Orthopaedic surgery for geriatric hip fracture. Main Outcome Measurements Patient demographics, medical comorbidities, hospitalization length, and admitting service. Negative binomial regression used to determine association between LOS and admitting service. Results Six hundred fourteen geriatric hip fracture patients were included in the analysis, of whom 49.2% of patients (n = 302) were admitted to the orthopaedic service and 50.8% (3 = 312) to the medicine service. The median LOS for patients admitted to orthopaedics was 4.5 days compared with 7 days for patients admitted to medicine (P < 0.0001). Readmission was also significantly higher for patients admitted to medicine (n = 92, 29.8%) than for those admitted to orthopaedics (n = 70, 23.1%). After controlling for important patient factors, it was determined that medicine patients are expected to stay about 1.5 times (incidence rate ratio: 1.48, P < 0.0001) longer in the hospital than orthopaedic patients. Conclusions This is the largest study to demonstrate that admission to the medicine service compared with the orthopaedic service increases a geriatric hip fractures patient’s expected LOS. Since LOS is a major driver of cost as well as a measure of quality care, it is important to understand the factors that lead to a longer hospital stay to better allocate hospital resources. Based on the results from our institution, orthopaedic surgeons should be aware that admission to medicine might increase a patient’s expected LOS. PMID:26371621
Background To investigate the characteristics of editors and criteria used by orthopaedic journal editors in assessing submitted manuscripts. Methods Between 2008 to 2009 all 70 editors of Medline listed orthopaedic journals were approached prospectively with a questionnaire to determine the criteria used in assessing manuscripts for publication. Results There was a 42% response rate. There was 1 female editor and the rest were male with 57% greater than 60 years of age. 67% of the editors worked in university teaching hospitals and 90% of publications were in English. The review process differed between journals with 59% using a review proforma, 52% reviewing an anonymised manuscript, 76% using a routine statistical review and 59% of journals used 2 reviewers routinely. In 89% of the editors surveyed, the editor was able to overrule the final decision of the reviewers. Important design factors considered for manuscript acceptance were that the study conclusions were justified (80%), that the statistical analysis was appropriate (76%), that the findings could change practice (72%). The level of evidence (70%) and type of study (62%) were deemed less important. When asked what factors were important in the manuscript influencing acceptance, 73% cited an understandable manuscript, 53% cited a well written manuscript and 50% a thorough literature review as very important factors. Conclusions The editorial and review process in orthopaedic journals uses different approaches. There may be a risk of language bias among editors of orthopaedic journals with under-representation of non-English publications in the orthopaedic literature. PMID:21527007
Patel, Alpesh A; Singh, Kern; Nunley, Ryan M; Minhas, Shobhit V
The drive for evidence-based decision-making has highlighted the shortcomings of traditional orthopaedic literature. Although high-quality, prospective, randomized studies in surgery are the benchmark in orthopaedic literature, they are often limited by size, scope, cost, time, and ethical concerns and may not be generalizable to larger populations. Given these restrictions, there is a growing trend toward the use of large administrative databases to investigate orthopaedic outcomes. These datasets afford the opportunity to identify a large numbers of patients across a broad spectrum of comorbidities, providing information regarding disparities in care and outcomes, preoperative risk stratification parameters for perioperative morbidity and mortality, and national epidemiologic rates and trends. Although there is power in these databases in terms of their impact, potential problems include administrative data that are at risk of clerical inaccuracies, recording bias secondary to financial incentives, temporal changes in billing codes, a lack of numerous clinically relevant variables and orthopaedic-specific outcomes, and the absolute requirement of an experienced epidemiologist and/or statistician when evaluating results and controlling for confounders. Despite these drawbacks, administrative database studies are fundamental and powerful tools in assessing outcomes on a national scale and will likely be of substantial assistance in the future of orthopaedic research.
Sacco, E; Marangi, F; Pinto, F; D'Addessi, A; Racioppi, M; Gulino, G; Volpe, A; Gardi, M; Bassi, P F
Statistical data referring to sports-related traumas of the urinary tract are quite scarce; nevertheless, it is possible to draw general data on the relationship between sports and urological traumas. Literature review of peer-reviewed articles published by May 2009. Urological traumas account for about 10% of all traumas, and about 13% of them is sports-related. Genitourinary traumas are among the most common cause of abdominal injuries in sports. Blunt injuries are more common than penetrating ones and renal injuries are by far the most common, followed by testicular injuries; ureters, bladder and penis injuries are much more infrequent. Considering chronic microtraumas, injuries of bulbar urethra are also common in sports that involve riding. Overall, the incidence of genitourinary trauma due to sports is low. Renal traumas in sports injuries usually consist of grade I-II lesions and usually do not require surgical treatment. Cycling is the sporting activity most commonly associated with genitourinary injuries, followed by winter sports, horse riding and contact/collision sports. Literature data suggest that significant injuries are rare also in athletes with only one testicle or kidney. General preventive measures against sport-related injuries, along with the use of protective cups for male external genitalia, are generally sufficient to reduce the incidence of urogenital trauma. Overall, studies show that urogenital injuries are uncommon in team and individual sports, and that most of them are low-grade injuries. Participation in sports that involve the potential for contact or collision needs to be carefully assessed in the athletes with only one testicle or kidney, even though urogenital injuries should not preclude sports participation to an appropriately informed and counseled patient. Further research is needed to acquire more knowledge on genitourinary injuries according to age, sports type and technical skill.
Adegboye, V O; Ladipo, J K; Brimmo, I A; Adebo, A O
A retrospective study was conducted at the cardiothoracic surgical unit of the University College Hospital, Ibadan on all consecutive, blunt chest injury patients treated between May 1975 and April 1999. The period of study was divided into 2 periods: May 1975-April 1987, May 1987-April 1999. The aim was to determine the pattern of injury, the management and complications of the injury among the treated. Blunt chest trauma patients were 69% (1331 patients) of all chest injury patients (1928 patients) treated. Mean age for the 2 periods was 38.3 +/- 15 years and 56.4 +/- 6.2 years, the male:female ratio was 4:1 and 2:1 respectively. The incidence of blunt chest trauma tripled in the second period. Blunt chest trauma was classified as involving bony chest wall or without the involvement of bony chest wall. Majority of the blunt chest injuries were minor chest wall injuries (68%, 905 patients), 7.6% (101 patients) had major but stable chest wall injuries, 10.8% (144 patients) had flail chest injuries. Thoracic injuries without fractures of bony chest wall occurred in 181 patients (13.6%). Seven hundred and eighty-seven patients (59.1%) had associated extra-thoracic injuries, in 426 patients (54.1%) two or more extra-thoracic systems were involved. While orthopaedic injury was the most frequent extra-thoracic injury (69.5%) associated with blunt chest trauma, craniospinal injury (31.9%) was more common injury among the patients with severe or life threatening chest trauma. The most common extra-thoracic operation was laparotomy (221 patients). Nine hundred and seventy patients (72.9%) had either closed thoracostomy drainage or clinical observation, 361 patients (27.1%) had major thoracic surgical intervention (emergent in 134 patients, late in 227 patients). Most of the severe lung contusion that needed ventilatory care (85 patients) featured among patients with bony chest wall injury, 15 were without chest wall injury. Majority of patients 63.2% (835 patients) had no
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Over years of practice, many beliefs and practices become entrenched as tried and tested, and we subconsciously believe they are based on scientific evidence. We identified nine such beliefs by interviewing orthopaedic surgeons in which studies (or lack thereof) apparently do not support such practices. These are: changing the scalpel blade after the skin incision to limit contamination; bending the patient’s knee when applying a thigh tourniquet; bed rest for treatment of deep vein thrombosis; antibiotics in irrigation solution; routine use of hip precautions; routine use of antibiotics for the duration of wound drains; routine removal of hardware in children; correlation between operative time and infection; and not changing dressings on the floor before scrubbing. A survey of 186 practicing orthopaedic surgeons in academic and community settings was performed to assess their routine practice patterns. We present the results of the survey along with an in-depth literature review of these topics. Most surgeon practices are based on a combination of knowledge gained during training, reading the literature, and personal experience. The results of this survey hopefully will raise the awareness of the selected literature for common practices. PMID:18726654
Giddins, G E; Kurer, M H
The use of handbooks is becoming more widespread in hospital medicine. A review of their use in British orthopaedics received 78 replies (29 per cent) representing 94 (30 per cent) of the orthopaedic units in the United Kingdom. Seventy-five per cent used a handbook, were preparing one or would like to have one. Recommendations are given for the content and format of a handbook, a specimen of which has been prepared.
Kuz, Julian E
War, considered to be one of the greatest causes of human suffering, often spurs some of the greatest advances in medical treatments. In the United States, the Civil War was a catalyst for the development of trauma management, including general wound management, amputation techniques, triage, and transportation of wounded soldiers. The War, by necessity, also accelerated surgical knowledge and treatment of gunshot wounds of the extremities more than any previous event. The War also served as the impetus for the specialization of surgical skills, hospital systems, and medical data collection. Orthopaedic surgery, at the time of the War, was not as yet a recognized specialty in the United States. However, the Civil War played an important role in the specialty's heritage and the creation of specialty orthopaedic and prosthetic hospitals. Although many discoveries in the area of orthopaedic surgery were not discovered until the 20th century, many basic orthopaedic procedures and techniques were developed during this war that continue to be used today, including Buck's traction, plaster splints, and open treatment of contaminated wounds. The first recorded attempts at open reduction-internal fixation techniques for gunshot fractures occurred during the War. Resection arthroplasties, shell and bone fragment extraction, and various types of amputation were improved because of the large numbers of casualties.
Atesok, Kivanc; Mabrey, Jay D; Jazrawi, Laith M; Egol, Kenneth A
Mastering rapidly evolving orthopaedic surgical techniques requires a lengthy period of training. Current work-hour restrictions and cost pressures force trainees to face the challenge of acquiring more complex surgical skills in a shorter amount of time. As a result, alternative methods to improve the surgical skills of orthopaedic trainees outside the operating room have been developed. These methods include hands-on training in a laboratory setting using synthetic bones or cadaver models as well as software tools and computerized simulators that enable trainees to plan and simulate orthopaedic operations in a three-dimensional virtual environment. Laboratory-based training offers potential benefits in the development of basic surgical skills, such as using surgical tools and implants appropriately, achieving competency in procedures that have a steep learning curve, and assessing already acquired skills while minimizing concerns for patient safety, operating room time, and financial constraints. Current evidence supporting the educational advantages of surgical simulation in orthopaedic skills training is limited. Despite this, positive effects on the overall education of orthopaedic residents, and on maintaining the proficiency of practicing orthopaedic surgeons, are anticipated.
De Kleijn, P; Blamey, G; Zourikian, N; Dalzell, R; Lobet, S
As haemophilic arthropathy and chronic synovitis are still the most important clinical features in people with haemophilia, different kinds of invasive and orthopaedic procedures have become more common during the last decades. The availability of clotting factor has made arthroplasty of one, or even multiple joints possible. This article highlights the role of physiotherapy before and after such procedures. Synovectomies are sometimes advocated in people with haemophilia to stop repetitive cycles of intra-articular bleeds and/or chronic synovitis. The synovectomy itself, however, does not solve the muscle atrophy, loss of range of motion (ROM), instability and poor propriocepsis, often developed during many years. The key is in taking advantage of the subsequent, relatively safe, bleed-free period to address these important issues. Although the preoperative ROM is the most important variable influencing the postoperative ROM after total knee arthroplasty, there are a few key points that should be considered to improve the outcome. Early mobilization, either manual or by means of a continuous passive mobilization machine, can be an optimal solution during the very first postoperative days. Muscle isometric contractions and light open kinetic chain exercises should also be started in order to restore the quadriceps control. Partial weight bearing can be started shortly after, because of quadriceps inhibition and to avoid excessive swelling. The use of continuous clotting factor replacement permits earlier and intensive rehabilitation during the postoperative period. During the rehabilitation of shoulder arthroplasty restoring the function of the rotator cuff is of utmost importance. Often the rotator cuff muscles are inhibited in the presence of pain and loss of ROM. Physiotherapy also assists in improving pain and maintaining ROM and strength. Functional weight-bearing tasks, such as using the upper limbs to sit and stand, are often discouraged during the first 6
Sansone, Randy A; Chang, Joy; Jewell, Bryan; Rock, Rachel
Childhood trauma has been empirically associated with various types of self-regulatory difficulties in adulthood. However, according to the extant literature, no study has examined relationships between various types of childhood trauma and compulsive buying behavior in adulthood. Using a self-report survey methodology in a cross-sectional consecutive sample of 370 obstetrics/gynecology patients, we examined five types of childhood trauma before the age of 12 years (i.e. witnessing violence, physical neglect, emotional abuse, physical abuse, sexual abuse) in relationship to compulsive buying as assessed by the Compulsive Buying Scale (CBS). All forms of trauma demonstrated statistically significant correlations with the CBS. Using a linear regression analysis, both witnessing violence and emotional abuse significantly contributed to CBS scores. Further analyses indicated that race did not moderate the relationship between childhood trauma and compulsive buying. Findings indicate that various forms of childhood trauma are correlated with compulsive buying behavior, particularly witnessing violence and emotional abuse.
Moffatt, Samuel Edwin
Hypovolaemic shock that results through traumatically inflicted haemorrhage can have disastrous consequences for the victim. Initially the body can compensate for lost circulating volume, but as haemorrhage continues compensatory mechanisms fail and the patient's condition worsens significantly. Hypovolaemia results in the lethal triad, a combination of hypothermia, acidosis and coagulopathy, three factors that are interlinked and serve to worsen each other. The lethal triad is a form of vicious cycle, which unless broken will result in death. This report will focus on the role of hypothermia (a third of the lethal triad) in trauma, examining literature to assess how prehospital temperature control can impact on the trauma patient. Spontaneous hypothermia following trauma has severely deleterious consequences for the trauma victim; however, both active warming of patients and clinically induced hypothermia can produce particularly positive results and improve patient outcome. Possible coagulopathic side effects of clinically induced hypothermia may be corrected with topical haemostatic agents, with the benefits of an extended golden hour given by clinically induced hypothermia far outweighing these risks. Active warming of patients, to prevent spontaneous trauma induced hypothermia, is currently the only viable method currently available to improve patient outcome. This method is easy to implement requiring simple protocols and contributes significantly to interrupting the lethal triad. However, the future of trauma care appears to lie with clinically induced therapeutic hypothermia. This new treatment provides optimism that in the future the number of deaths resulting from catastrophic haemorrhaging may be significantly lessened.
Campbell, Allison A.
During the past century, man-made materials and devices have been developed to the point at which they have been used successfully to replace and/or restore function to diseased or damaged tissues. In the field of orthopaedics, the use of metal implants has significantly improved the quality of life for countless individuals. Critical factors for implant success include proper design, material selection, and biocompatibility. While early research focused on the understanding biomechanical properties of the metal device, recent work has turned toward improving the biological properties of these devices. This has lead to the introduction of calcium phosphate (CaP) bioceramics as a bioactive interface between the bulk metal impart and the surrounding tissue. The first calcium phosphate coatings where produced via vapor phase routes but more recently, there has been the emergence of solution based and biomimetic methods. While each approach has its own intrinsic materials and biological properties, in general CaP coatings have the promise to improve implant biocompatibility and ultimately implant longevity.
Rodts, Mary F; Glanzman, Renée; Gray, Adam; Johnson, Randal; Viellieu, Dennis; Hachem, Fadi
With increased demand to provide quality care for patients, orthopaedic practices will need to develop ways to efficiently collect and manage data to support the care that they provide. An outcomes management program must be efficient and consistent to provide good data. This article describes the implementation of an outcomes program at one large private orthopaedic practice within an academic medical setting.
AlQahtani, Saad M.; Alzahrani, Mohammad M.; Harvey, Edward J.
Background Occupational injuries and hazards have gained increased attention in the surgical community in general and in the orthopedic literature specifically. The aim of this study was to assess prevalence and characteristics of musculoskeletal disorders among orthopedic trauma surgeons and the impact of these injuries on the surgeons’ practices. Methods We sent a modified version of the physical discomfort survey to surgeon members of the Orthopaedic Trauma Association (OTA) via email. Data were collected and descriptive statistics were analyzed. Results A total of 86 surgeons completed the survey during the period of data collection; 84.9% were men, more than half were 45 years or older and 40.6% were in practice for 10 years or more. More than 66% of respondents reported a musculoskeletal disorder that was related to work; the most common was low back pain (29.3%). The number of body regions involved and disorders diagnosed was associated with increasing age and number of years in practice (p = 0.033). Time off work owing to these disorders was associated with working in a private setting (p = 0.045) and working in more than 1 institute (p = 0.009). Conclusion To our knowledge, our study is the first to report a high percentage of orthopedic trauma surgeons sustaining occupational injuries some time in their careers. The high cost of management and rehabilitation of these injuries in addition to the related number of missed work days indicate the need for increased awareness and implementation of preventive measures. PMID:26812408
Pannu, Gurpal S; Shah, Mitesh P; Herman, Marty J
Cervical spine clearance in the pediatric trauma patient represents a particularly challenging task. Unfortunately, standardized clearance protocols for pediatric cervical clearance are poorly reported in the literature and imaging recommendations demonstrate considerable variability. With the use of a web-based survey, this study aims to define the methods utilized by pediatric trauma centers throughout North America. Specific attention was given to the identification of personnel responsible for cervical spine care, diagnostic imaging modalities used, and the presence or absence of a written pediatric cervical spine clearance protocol. A 10-question electronic survey was given to members of the newly formed Pediatric Cervical Spine Study Group, all of whom are active POSNA members. The survey was submitted via the online service SurveyMonkey (https://www.surveymonkey.com/r/7NVVQZR). The survey assessed the respondent's institution demographics, such as trauma level and services primarily responsible for consultation and operative management of cervical spine injuries. In addition, respondents were asked to identify the protocols and primary imaging modality used for cervical spine clearance. Finally, respondents were asked if their institution had a documented cervical spine clearance protocol. Of the 25 separate institutions evaluated, 21 were designated as level 1 trauma centers. Considerable variation was reported with regards to the primary service responsible for cervical spine clearance. General Surgery/Trauma (44%) is most commonly the primary service, followed by a rotating schedule (33%), Neurosugery (11%), and Orthopaedic Surgery (8%). Spine consults tend to be seen most commonly by a rotating schedule of Orthopaedic Surgery and Neurosurgery. The majority of responding institutions utilize computed tomographic imaging (46%) as the primary imaging modality, whereas 42% of hospitals used x-ray primarily. The remaining institutions reported using a
Bhangu, A; Hood, E; Datta, A; Mangaleshkar, S
Informed consent in the modern era is a common and important topic both for the well-informed patient and to prevent unnecessary litigation. However, the effectiveness of informed consent in trauma patients is an under-researched area. This paper aims to assess the differences in patient recall of the consent process and desire for information by performing a comparative analysis between orthopaedic trauma and elective patients. Information from 41 consecutive elective operations and 40 consecutive trauma operations was collected on the first post-operative day. 100% of elective patients and 90% of trauma patients knew what operation they had received (p = 0.06). Overall recall of complications was poor, but was significantly lower in trauma patients compared with elective patients (62% vs 22%, p<0.001). 30% of trauma patients desired more information about their operation compared to 12% of elective patients (p = 0.049), although only 35% of trauma patients wanted written as well as verbal explanations, compared to 85% of elective patients p<0.001). Overall 100% of elective and 90% of trauma patients were happy with the consent process (p = 0.06). Subset analysis of neck of femur compared to other trauma patients showed that the above factors were not significantly different between the two groups. Recall of complications in the trauma patients is significantly lower than in elective patients, although both groups scored poorly overall. Repeated verbal explanations should be reinforced with the option of additional information leaflets for trauma operations. Further research into the usefulness of DVDs for commonly performed operations is warranted, although official internet resources may be more cost-effective.
Qureshi, Sheeraz; Lu, Young; McAnany, Steven; Baird, Evan
Intraoperative imaging and navigation systems have revolutionized orthopaedic surgery for the spine, joints, and orthopaedic trauma. Imaging modalities such as the isocentric C-arm, O-arm imaging, and intraoperative MRI or navigation systems allow the visualization of surgical instruments and implants relative to a three-dimensional CT image or MRI. Studies show that these technologies lower the rates of implant misplacement and inadequate fracture reduction, thereby improving surgical outcomes and reducing reoperation rates. An additional benefit is reduced radiation exposure compared with that for conventional fluoroscopy. Concerns surrounding adoption of these technologies include cost and increased operating times, but improvements in design and protocol may improve the integration of these imaging modalities into the operating room.
Muscat, J O; Rogers, W; Cruz, A B; Schenck, R C
Combined orthopaedic and vascular injuries are becoming more common owing to an increasing incidence of high-energy trauma and gunshot wounds. We present our experience using the posteromedial approach in treating eight orthopaedic patients with popliteal arterial injuries. All patients underwent popliteal exploration by a vascular surgeon through a posteromedial approach (releasing the pes anserinus and the medial gastrocnemius). The arterial injuries were reconstructed in five patients using a reverse saphenous vein graft and directly repaired in three patients. Two patients had delayed healing of their incisions as a result of the original injury. There were no neural injuries. The posteromedial approach is extensile and utilitarian, and it represents the exposure of choice for arterial injuries about the knee.
Myositis ossificans traumatica is a relatively common injury associated with sports especially those involving contact. It continues to frustrate both athlete and health practitioner alike due to its continued lack of treatment options and a lengthy natural history. This case study chronicles the observation of a 34 year old recreational ice hockey player who presented 7 years post-trauma, was diagnosed with myositis ossificans traumatica and was followed up on 8 years later (15 years post-trauma). This case report is suspected to be the first published case study of its kind. The literature review outlines the various types of myositis ossificans, its incidence, pathogenesis, differential diagnoses including osteosarcoma, and the various methods/modalities reported in its treatment. PMID:21120014
As road traffic fatalities have emerged among the leading global threats to human health and safety, there is an imminent need for the mobilization of large medical organizations and private companies. Collectively, these partnerships can have a tremendous impact on road traffic safety through garnering funding for important initiatives, lobbying governments for policy reforms, and implementing organizational frameworks that foster the transfer of health-care knowledge to optimize trauma care in developing countries. In particular, concerted efforts by major orthopaedic associations can directly enable overwhelmed health-care systems to improve upon their prehospital care, emergency triage systems, trauma care protocols, and rehabilitation programs. The "SIGN" and "Broken Earth" programs serve as prime examples of the powerful impact international trauma organizations can have on global trauma initiatives.
Falasca, Tony; Caulfield, Thomas J.
Describes some classic causes of trauma and symptoms that can result when a child has been traumatized. Lists several factors that effect the degree to which a child is affected by trauma. Categories a wide range of behaviors displayed by the victims into three groups: affect, memories, and behaviors. Discusses various considerations when…
Falasca, Tony; Caulfield, Thomas J.
Describes some classic causes of trauma and symptoms that can result when a child has been traumatized. Lists several factors that effect the degree to which a child is affected by trauma. Categories a wide range of behaviors displayed by the victims into three groups: affect, memories, and behaviors. Discusses various considerations when…
Stem cell research arose from the need to explore new therapeutic possibilities for intractable and lethal diseases. Although musculoskeletal disorders are basically nonlethal, their high prevalence and relative ease of performing clinical trials have facilitated the clinical application of stem cells in this field. However, few reliable clinical studies have been published, despite the plethora of in vitro and preclinical studies in stem cell research for regenerative medicine in the musculoskeletal system. Stem cell therapy can be applied locally for bone, cartilage and tendon regeneration. Candidate disease modalities in bone regeneration include large bone defects, nonunion of fractures, and osteonecrosis. Focal osteochondral defect and osteoarthritis are current targets for cartilage regeneration. For tendon regeneration, bone-tendon junction problems such as rotator cuff tears are hot topics in clinical research. To date, the literature supporting stem cell-based therapies comprises mostly case reports or case series. Therefore, high-quality evidence, including from randomised clinical trials, is necessary to define the role of cell-based therapies in the treatment of musculoskeletal disorders. It is imperative that clinicians who adopt stem cell treatment into their practices possess a good understanding of the natural course of the disease. It is also highly recommended that treating physicians do not thrust aside the concomitant use of established measures until stem cell therapy is evidently proved worthy in terms of efficacy and cost. The purpose of this review is to summarise on the current status of stem cell application in the orthopaedic field along with the author's view of future prospects.
Wang, Dean; Rugg, Caitlin Marie; Mayer, Erik; Sulzicki, Pamela; Vail, Jeremy; Hame, Sharon L.
Objectives: Orthopaedic injury and surgery is relatively common in National Collegiate Athletic Association (NCAA) athletes and can have devastating career consequences. However, there is a paucity of data regarding predictors of orthopaedic surgery in collegiate athletes. The purpose of this study was to analyze player-related predictors of orthopaedic surgery, including that of the shoulder, hip, and knee, in NCAA athletes. Methods: All NCAA Division I collegiate athletes at a single institution who began participation from the 2003-2004 through 2008-2009 seasons were retrospectively identified. Player-related factors, including gender, sport, and any pre-college upper or lower extremity orthopaedic surgery, were elicited through pre-participation evaluations (PPEs). Athletes who underwent an orthopaedic surgery in college were identified through the Sports Injury Monitoring System and medical records. All patient-related independent variables were included in a multiple Cox regression model. Exposure time was calculated from the date of PPE to the date of surgery (event) or to the end of the collegiate athletic career (censored). Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. Significance was set at P < 0.05. Results: In total, 1,142 athletes in 12 sports (baseball/softball, basketball, football, golf, gymnastics, rowing, swimming & diving, soccer, tennis, track & field/cross country, volleyball, water polo) were identified. There were 262 documented orthopaedic surgeries, including those involving the shoulder (n = 34), hip (n = 25), and knee (n = 72), in 182 athletes. Using the multiple Cox regression model, pre-college lower extremity surgery was an independent predictor of orthopaedic (P = 0.004, HR = 1.88) and knee (P < 0.001, HR = 3.91) surgery, and type of sport was an independent predictor of orthopaedic (P < 0.001), shoulder (P = 0.002), and knee surgery (P < 0.001) (Table 1). Participation in gymnastics, basketball, and
Yayac, Michael; Javandal, Mitra; Mulcahey, Mary K.
Background: A substantial number of orthopaedic surgeons apply for sports medicine fellowships after residency completion. The Internet is one of the most important resources applicants use to obtain information about fellowship programs, with the program website serving as one of the most influential sources. The American Orthopaedic Society for Sports Medicine (AOSSM), San Francisco Match (SFM), and Arthroscopy Association of North America (AANA) maintain databases of orthopaedic sports medicine fellowship programs. A 2013 study evaluated the content and accessibility of the websites for accredited orthopaedic sports medicine fellowships. Purpose: To reassess these websites based on the same parameters and compare the results with those of the study published in 2013 to determine whether any improvement has been made in fellowship website content or accessibility. Study Design: Cross-sectional study. Methods: We reviewed all existing websites for the 95 accredited orthopaedic sports medicine fellowships included in the AOSSM, SFM, and AANA databases. Accessibility of the websites was determined by performing a Google search for each program. A total of 89 sports fellowship websites were evaluated for overall content. Websites for the remaining 6 programs could not be identified, so they were not included in content assessment. Results: Of the 95 accredited sports medicine fellowships, 49 (52%) provided links in the AOSSM database, 89 (94%) in the SFM database, and 24 (25%) in the AANA database. Of the 89 websites, 89 (100%) provided a description of the program, 62 (70%) provided selection process information, and 40 (45%) provided a link to the SFM website. Two searches through Google were able to identify links to 88% and 92% of all accredited programs. Conclusion: The majority of accredited orthopaedic sports medicine fellowship programs fail to utilize the Internet to its full potential as a resource to provide applicants with detailed information about the
Lim, Hyeung C; Adie, Sam; Naylor, Justine M; Harris, Ian A
We investigated the proportion of orthopaedic procedures supported by evidence from randomised controlled trials comparing operative procedures to a non-operative alternative. Orthopaedic procedures conducted in 2009, 2010 and 2011 across three metropolitan teaching hospitals were identified, grouped and ranked according to frequency. Searches of the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) were performed to identify RCTs evaluating the most commonly performed orthopaedic procedures. Included studies were categorised as "supportive" or "not supportive" of operative treatment. A risk of bias analysis was conducted for included studies using the Cochrane Collaboration's Risk of Bias tool. A total of 9,392 orthopaedic procedures were performed across the index period. 94.6% (8886 procedures) of the total volume, representing the 32 most common operative procedure categories, were used for this analysis. Of the 83 included RCTs, 22.9% (19/83) were classified as supportive of operative intervention. 36.9% (3279/8886) of the total volume of procedures performed were supported by at least one RCT showing surgery to be superior to a non-operative alternative. 19.6% (1743/8886) of the total volume of procedures performed were supported by at least one low risk of bias RCT showing surgery to be superior to a non-operative alternative. The level of RCT support for common orthopaedic procedures compares unfavourably with other fields of medicine.
... War Specific to Women Types of Trauma War Terrorism Violence and Abuse Disasters Is it PTSD? Treatment ... Overview Types of Trauma Trauma Basics Disaster and Terrorism Military Trauma Violence & other Trauma Assessment Assessment Overview ...
... War Specific to Women Types of Trauma War Terrorism Violence and Abuse Disasters Is it PTSD? Treatment ... Overview Types of Trauma Trauma Basics Disaster and Terrorism Military Trauma Violence & other Trauma Assessment Assessment Overview ...
Millar, Ian L; McGinnes, Rosemary A; Williamson, Owen; Lind, Folke; Jansson, Karl-Åke; Hajek, Michal; Smart, David; Fernandes, Tiago; Miller, Russell; Myles, Paul; Cameron, Peter
Open fractures with significant soft tissue injury are associated with high rates of complications, such as non-union, infection, chronic pain and disability. Complications often require further inpatient care, and in many cases, multiple operations and prolonged rehabilitation. Use of hyperbaric oxygen therapy as an adjunct to standard orthopaedic trauma care has the potential to reduce the complications of musculoskeletal injury and thus improve outcomes. Two previous randomised trials have suggested some positive effect, but neither functional measures nor long-term outcomes were reported. An international, multicentre, randomised, open-label, clinical trial. Patients with trauma with an acute open fracture of the tibia with severe soft tissue injury (Gustilo grade 3) and high risk of injury-related complications were recruited from participating major trauma hospitals with hyperbaric facilities. Patients were enrolled with the expectation of commencing 12 sessions of hyperbaric oxygen therapy within 48 h of injury. The primary outcome measure is the incidence of acute complications of the open fracture wound at 14 days. Other short-term outcome measures include amputation, need for fasciotomy, time until wound closure, breakdown of closed wounds, time until definitive orthopaedic fixation, number of operative procedures, intensive care stay and hospital stay. Long-term follow-up will continue for 2 years postinjury. Ethics approval was given by The Alfred Health Human Ethics Committee (206/04) and the Monash University Human Research Ethics Committee (CF07/4208). Approval was also obtained from the institutional research ethics committee at each participating site. This study will make a significant contribution to the trauma literature and should answer the question of whether hyperbaric oxygen therapy can significantly improve outcomes in severe lower limb trauma. Collective study results will be published in international journals and presented at relevant
Martínez-Piñeiro, Luis; Djakovic, Nenad; Plas, Eugen; Mor, Yoram; Santucci, Richard A; Serafetinidis, Efraim; Turkeri, Levent N; Hohenfellner, Markus
These guidelines were prepared on behalf of the European Association of Urology (EAU) to assist urologists in the management of traumatic urethral injuries. To determine the optimal evaluation and management of urethral injuries by review of the world's literature on the subject. A working group of experts on Urological Trauma was convened to review and summarize the literature concerning the diagnosis and treatment of genitourinary trauma, including urethral trauma. The Urological Trauma guidelines have been based on a review of the literature identified using on-line searches of MEDLINE and other source documents published before 2009. A critical assessment of the findings was made, not involving a formal appraisal of the data. There were few high-powered, randomized, controlled trials in this area and considerable available data was provided by retrospective studies. The Working Group recognizes this limitation. The full text of these guidelines is available through the EAU Central Office and the EAU website (www.uroweb.org). This article comprises the abridged version of a section of the Urological Trauma guidelines. Updated and critically reviewed Guidelines on Urethral Trauma are presented. The aim of these guidelines is to provide support to the practicing urologist since urethral injuries carry substantial morbidity. The diversity of urethral injuries, associated injuries, the timing and availability of treatment options as well as their relative rarity contribute to the controversies in the management of urethral trauma. Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Corre, Pierre; Arzul, Ludovic; Khonsari, Roman Hossein; Mercier, Jacques
The human face contains the sense organs and is responsible for essential functions: swallowing, chewing, speech, breathing and communication. It is also and most importantly the seat of a person's identity. Multiple trauma adds a life-threatening dimension to the physical and psychological impact of a facial trauma.
Heim, C; Bosisio, F; Roth, A; Bloch, J; Borens, O; Daniel, R T; Denys, A; Oddo, M; Pasquier, M; Schmidt, S; Schoettker, P; Zingg, T; Wasserfallen, J B
Switzerland, the country with the highest health expenditure per capita, is lacking data on trauma care and system planning. Recently, 12 trauma centres were designated to be reassessed through a future national trauma registry by 2015. Lausanne University Hospital launched the first Swiss trauma registry in 2008, which contains the largest database on trauma activity nationwide. Prospective analysis of data from consecutively admitted shock room patients from 1 January 2008 to 31 December 2012. Shock room admission is based on physiology and mechanism of injury, assessed by prehospital physicians. Management follows a surgeon-led multidisciplinary approach. Injuries are coded by Association for the Advancement of Automotive Medicine (AAAM) certified coders. Over the 5 years, 1,599 trauma patients were admitted, predominantly males with a median age of 41.4 years and median injury severity score (ISS) of 13. Rate of ISS >15 was 42%. Principal mechanisms of injury were road traffic (40.4%) and falls (34.4%), with 91.5% blunt trauma. Principal patterns were brain (64.4%), chest (59.8%) and extremity/pelvic girdle (52.9%) injuries. Severe (abbreviated injury scale [AIS] score ≥ 3) orthopaedic injuries, defined as extremity and spine injuries together, accounted for 67.1%. Overall, 29.1% underwent immediate intervention, mainly by orthopaedics (27.3%), neurosurgeons (26.3 %) and visceral surgeons (13.9%); 43.8% underwent a surgical intervention within the first 24 hours and 59.1% during their hospitalisation. In-hospital mortality for patients with ISS >15 was 26.2%. This is the first 5-year report on trauma in Switzerland. Trauma workload was similar to other European countries. Despite high levels of healthcare, mortality exceeds published rates by >50%. Regardless of the importance of a multidisciplinary approach, trauma remains a surgical disease and needs dedicated surgical resources.
Fagg, P. S.
Intravenous regional anaesthesia in lower limb orthopaedic surgery has rarely been reported. A prospective series of 50 orthopaedic procedures performed with prilocaine is presented. In over 90% of patients excellent anaesthesia was obtained. PMID:3426092
Bates, P; Parker, P; McFadyen, I; Pallister, I
Trauma care has evolved rapidly over the past decade. The benefits of operative fracture management in major trauma patients are well recognised. Concerns over early total care arose when applied broadly. The burden of additional surgical trauma could constitute a second hit, fuelling the inflammatory response and precipitating a decline into acute respiratory distress syndrome, sepsis and multiple organ dysfunction syndrome. Temporary external fixation aimed to deliver the benefits of fracture stabilisation without the risk of major surgery. This damage control orthopaedics approach was advocated for those in extremis and a poorly defined borderline group. An increasing understanding of the physiological response to major trauma means there is now a need to refine our treatment options. A number of large scale retrospective reviews indicate that early definitive fracture fixation is beneficial in the majority of major trauma patients. It is recommended that patients are selected appropriately on the basis of their response to resuscitation. The hope is that this approach (dubbed ‘safe definitive fracture surgery’ or ‘early appropriate care’) will herald an era when care is individualised for each patient and their circumstances. The novel Damage Control in Orthopaedic Trauma Surgery course at The Royal College of Surgeons of England aims to equip senior surgeons with the insights and mindset necessary to contribute to this key decision making process as well as also the technical skills to provide damage control interventions when needed, relying on the improved techniques of damage control resuscitation and advances in the understanding of early appropriate care. PMID:27023640
Green, David P; DeLee, Jesse C
On April 6, 1917, the United States declared war on Germany and entered what was then called the Great War. Among the first officers sent to Europe were 21 orthopaedic surgeons in the so-called First Goldthwait Unit. Prior to the war, orthopaedics had been a nonoperative "strap-and-buckle" specialty that dealt primarily with infections, congenital abnormalities, and posttraumatic deformity. The Great War changed all of that forever, creating a new surgical specialty with emphasis on acute treatment, prevention of deformity, restoration of function, and rehabilitation.
Fleury, Thierry Rod; Holzer, Nicolas; Fleury, Mapi; Hoffmeyer, Pierre J
The recent progress in oncologic management of patients with metastatic disease has permitted a significant improvement of their life expectancy. Many of these patients will suffer from complications related to bone metastasis. Unfortunately an orthopaedic treatment is seldom offered to them, mainly because of the misconception that this would not bring them any benefice. However these patients are often good candidates for an orthopaedic management, which objectives are to relieve pain and to re-establish their quality of life. The available surgical techniques are well described and the management protocols are clearly defined, as are the expectable complications and the errors that must not be done.
Chan, Kai-Ming; Fong, Daniel Tik-Pui; Hong, Youlian; Yung, Patrick Shu-Hang; Lui, Pauline Po-Yee
This article proposes a new paradigm, "Orthopaedic sport biomechanics", for the understanding of the role of biomechanics in preventing and managing sports injury. Biomechanics has three main roles in this paradigm: (1) injury prevention, (2) immediate evaluation of treatment, and (3) long-term outcome evaluation. Related previous studies showing the approach in preventing and managing anterior cruciate ligament rupture and anterior talofibular ligament tear are highlighted. Orthopaedics and biomechanics specialists are encouraged to understand what they could contribute to the current and future practice of sports medicine.
Dincyurek, Sibel; Arsan, Nihan; Caglar, Mehmet
Although various studies have been conducted in the field of orthopaedic impairment, research regarding computer education for orthopaedically impaired individuals remains insufficient. This study aimed to evaluate the use of computers by orthopaedically impaired individuals from a wider perspective. The findings of the study emphasise the…
Practice-based learning and improvement is an important skill set to develop during an orthopaedic trauma fellowship and is 1 of the 6 core competencies stated by the ACGME. The review of clinic cases is best done using a few simple models to develop a structured approach for studying cases. Three common sense and easy-to-use strategies to improve clinical practice are as follows: performing each case three times, studying the 4 quadrants of patient outcomes, and the application of the Pareto 80/20 rule. These principles help to develop a structured approach for analyzing and thinking about practice-based experiences.
Cozowicz, C; Poeran, J; Memtsoudis, S G
Recent studies have linked the use of regional anaesthesia to improved outcomes. Epidemiological research on utilization, trends, and disparities in this field is sparse; however, large nationally representative database constructs containing anaesthesia-related data, demographic information, and multiyear files are now available. Together with advances in research methodology and technology, these databases provide the foundation for epidemiological research in anaesthesia. We present an overview of selected studies that provide epidemiological data and describe current anaesthetic practice, trends, and disparities in orthopaedic surgery in particular. This literature suggests that that even among orthopaedic surgical procedures, which are highly amenable to regional anaesthetic techniques, neuraxial anaesthetics and peripheral nerve blocks are used in only a minority of procedures. Trend analyses show that peripheral nerve blocks are gaining in popularity, whereas use of neuraxial anaesthetics is remaining relatively unchanged or even declining over time. Finally, significant disparities and variability in anaesthetic care seem to exist based on demographic and health-care-related factors. With anaesthesia playing an increasingly important part in population-based health-care delivery and evidence indicating improved outcome with use of regional anaesthesia, more research in this area is needed. Furthermore, prevalent disparities and variabilities in anaesthesia practice need to be specified further and addressed in the future. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Abbassian, Ali; Datla, Balarama; Brooks, RA
INTRODUCTION We performed a questionnaire study to establish the frequency and consequences of the detection of orthopaedic implants by airport security and to help us advise patients correctly. All published literature on this subject is based on experimental studies and no ‘real-life’ data are available. PATIENTS AND METHODS A total of 200 patients with a variety of implants were identified. All patients were sent a postal questionnaire enquiring about their experience with airport security since their surgery. RESULTS Of the cohort, 154 (77%) patients responded. About half of the implants (47%) were detected, but the majority of patients (72%) were not significantly inconvenienced. When detected, only 9% of patients were asked for documentary evidence of their implant. We also found that patients with a total knee replacement (TKR) had a greater chance of detection as compared to those with a total hip replacement (THR; 71% versus 31%; P = 0.03). CONCLUSIONS All patients, and in particular those with a TKR, can be re-assured that, although they have a fair chance of detection by airport security, a major disruption to their journey is unlikely. We advise that documentation to prove the presence of an orthopaedic implant should be offered to those who are concerned about the potential for inconvenience, but such documentation is not required routinely. PMID:17394716
Nobile, M; Navone, P; Domeniconi, G; Della Valle, A; Daolio, P A; Buccino, N A; Auxilia, F
Literature reports an incidence of surgical site infections (SSIs) in oncological patients undergoing prosthetic replacement between 8% and 35% after first implantation and 43% after revision. The purpose of this retrospective study, conducted at the oncologic orthopaedic unit of G. Pini Orthopaedic Hospital in Milan, was to evaluate: - number of SSIs in oncological megaprosthetic reconstruction between 2008 and 2011, - possible risk factors associated with the onset of SSIs, - antibiotic prophylaxis applied. We reviewed medical records of patients who underwent megaprosthetic reconstruction and collected data on whole treatment and follow up after discharge, focusing on possible risk factors implied in the onset of SSIs such as patient characteristics, site of surgery, duration of surgery, number of persons in the operating room, size of resection, antibiotic prophylaxis. We recorded every SSI which met the criteria set by the Hospital in Europe Link for Infection Control through Surveillance (HELICS) protocol. One-hundred and eleven surgeries were evaluated. Administration of prophylaxis was generally recorded and continued postoperatively for an average of 18.89 days, often depending on the length of the post-surgical stay. Mean duration of surgery was 254 minutes with an average of 7 persons attending the operating room. We recorded 6 SSIs.
Bergovec, Marko; Orlic, Dubravko
The literature contains limited and contradictory information regarding the amount of physical effort and/or emotional stress needed to perform surgery. We therefore investigated cardiovascular response to psychophysical stress in orthopaedic surgeons while they were performing surgery. We monitored 29 male orthopaedic surgeons from four university centers while they performed total hip arthroplasties. Changes in their cardiovascular parameters were recorded by ambulatory monitoring methods. Exercise stress testing of each participant was used as a control state. We compared the cardiovascular response during surgery to energy requirements of everyday activities. Preoperative and postoperative testing showed lower values of cardiovascular parameters than during physically less difficult parts of the operation; physically more difficult phases of the operation additionally increased the values of parameters. We concluded performing total hip arthroplasty increases surgeons' cardiovascular parameters because of psychologic stress and physical effort. Excitement of the cardiovascular system during total hip arthroplasty appears similar to the excitement during moderate-intensity daily activities, such as walking the dog, leisurely bicycling, or climbing stairs.
The literature contains limited and contradictory information regarding the amount of physical effort and/or emotional stress needed to perform surgery. We therefore investigated cardiovascular response to psychophysical stress in orthopaedic surgeons while they were performing surgery. We monitored 29 male orthopaedic surgeons from four university centers while they performed total hip arthroplasties. Changes in their cardiovascular parameters were recorded by ambulatory monitoring methods. Exercise stress testing of each participant was used as a control state. We compared the cardiovascular response during surgery to energy requirements of everyday activities. Preoperative and postoperative testing showed lower values of cardiovascular parameters than during physically less difficult parts of the operation; physically more difficult phases of the operation additionally increased the values of parameters. We concluded performing total hip arthroplasty increases surgeons’ cardiovascular parameters because of psychologic stress and physical effort. Excitement of the cardiovascular system during total hip arthroplasty appears similar to the excitement during moderate-intensity daily activities, such as walking the dog, leisurely bicycling, or climbing stairs. PMID:18196425
Aresti, Nick; Ramachandran, Manoj
Eponyms are widely used in medicine and their use has been the subject of much debate recently. Advocates stress their historical significance, their ability to simplify complex terminology and their addition of character to science. Opponents cite the controversy among those eponyms and highlight the lack of both scientific and historical accuracy. The law of Nonoriginal Malappropriate Eponymous Nomenclature (NOMEN) suggests that no phenomenon is named after the individual(s) who originally described it. We aimed to determine whether this law is applicable to various clinical conditions and signs relevant to paediatric orthopaedics. We selected a series of 10 eponyms and performed a thorough literature review. In all cases, a description was identified preceding that from whom the disease received its eponymous name. We were also able to identify what we believe to be the earliest recorded description of each disease and sign. Our examples confirm the law of NOMEN in the field of paediatric orthopaedics. We suggest that irregularities in the descriptions and meanings of eponyms are identified and updated.
Zhou, R; Liu, B; Lin, K; Wang, R; Qin, Z; Liao, R; Qiu, Y
Extracorporeal membrane oxygenation (ECMO) may offer life-saving treatment in severe pulmonary contusion or acute respiratory distress syndrome when conventional treatments have failed. However, because of the bleeding risk of systemic anticoagulation, ECMO should be performed only as a last resort in multiple trauma victims. Here, we report ECMO as a bridge for right main bronchus reconstruction and recovery of traumatic wet lung in a 31-year-old male multi-trauma patient with right main bronchial disruption, bilateral pulmonary contusion, cerebral contusion and long bone fracture. The patient was discharged without any obvious complication. ECMO support in a traumatic brain injured patient with severe hypoxemia caused by lung contusion and/or tracheal bronchus disruption is not an absolute contraindication.
Quick, James Campbell; Sime, Wesley E.; Novicoff, Wendy M.; Einhorn, Thomas A.
Stress, emotional exhaustion, and burnout are widespread in the medical profession in general and in orthopaedic surgery in particular. We attempted to identify variables associated with burnout as assessed by validated instruments. Surveys were sent to 282 leaders from orthopaedic surgery academic departments in the United States by e-mail and mail. Responses were received from 195 leaders for a response rate of 69%. The average surgeon worked 68.3 hours per week and more than ½ of this time was allocated to patient care. Highest stressors included excessive workload, increasing overhead, departmental budget deficits, tenure and promotion, disputes with the dean, and loss of key faculty. Personal-professional life imbalance was identified as an important risk factor for emotional exhaustion. Withdrawal, irritability, and family disagreements are early warning indicators of burnout and emotional exhaustion. Orthopaedic leaders can learn, and potentially model, ways to mitigate stress from other high-stress professions. Building on the strength of marital and family bonds, improving stress management skills and self-regulation, and improving efficiency and productivity can combine to assist the orthopaedic surgery leader in preventing burnout and emotional exhaustion. Electronic supplementary material The online version of this article (doi:10.1007/s11999-008-0622-8) contains supplementary material, which is available to authorized users. PMID:19030943
Award Number: W81XWH-10-1-0627 TITLE:“Laser Applications on Orthopaedic Bone Repair” PRINCIPAL INVESTIGATOR: Kotaro Sena , D.D.S., Ph.D...6. AUTHOR(S) 5d. PROJECT NUMBER Kotaro Sena , D.D.S., Ph.D.; Amarjit S. Virdi, Ph.D. 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION
Hoppe, Daniel J; Bhandari, Mohit
Evidence-based medicine was recently noted as one of the top 15 most important medical discoveries over the past 160 years. Since the term was coined in 1990, EBM has seen unparalleled adoption in medicine and surgery. We discuss the early origins of EBM and its dissemination in medicine, especially orthopaedic surgery. PMID:19826513
Lippert, Frederick G.; And Others
The course described and evaluated here was developed at the University of Washington School of Medicine to teach 20 orthopaedic residents operative techniques, instrument usage, and safety precautions outside of the operating room without hazard to the patient or regard to time constraints. (JT)
Lippert, Frederick G.; And Others
The course described and evaluated here was developed at the University of Washington School of Medicine to teach 20 orthopaedic residents operative techniques, instrument usage, and safety precautions outside of the operating room without hazard to the patient or regard to time constraints. (JT)
Buckwalter, Joseph A; Elkins, Jacob M
Breakthrough advances in medicine almost uniformly result from the translation of new basic scientific knowledge into clinical practice, rather than from assessment, modification or refinement of current methods of diagnosis and treatment. However, as is intuitively understood, those most responsible for scientific conception and creation-scientists - are generally not the ones applying these advances at the patient's bedside or the operating room, and vice versa. Recognition of the scarcity of clinicians with a background that prepares them to develop new basic knowledge, and to critically evaluate the underlying scientific basis of methods of diagnosis and treatment, has led to initiatives including federally funded Physician-Scientist programs, whereby young, motivated scholars begin a rigorous training, which encompasses education and mentorship within both medical and scientific fields, culminating in the conferment of both MD and PhD degrees. Graduates have demonstrated success in integrating science into their academic medical careers. However, for unknown reasons, orthopaedic surgery, more than other specialties, has struggled to recruit and retain physician-scientists, who possess a skill set evermore rare in today's increasingly complicated medical and scientific landscape. While the reasons for this shortfall have yet to be completely elucidated, one thing is clear: If orthopaedics is to make significant advances in the diagnosis and treatment of musculoskeletal diseases and injuries, recruitment of the very best and brightest physician-scientists to orthopaedics must become a priority. This commentary explores potential explanations for current low-recruitment success regarding future orthopaedic surgeon-scientists, and discusses avenues for resolution.
Miller, George E.; And Others
A four year study was initiated to systematically improve the certification procedures of the American Board of Orthopaedic Surgery. Consequently, the immediate research aim was the development of more valid and reliable techniques in assessing professional competence in orthopedics. A definition of professional competence was reached through…
Daruwalla, Zubin J; Collins, D Ronan; Moore, David P
The remote presence robotic system (RPRS) enables an individual to "be in two places at once". Its application includes various uses in medicine and surgery. However, its usefulness in the field of orthopaedic surgery has not been described. The objective of our pilot study was to determine patient and nursing staff satisfaction with the RPRS in an orthopaedic clinical setting in Ireland. We performed evening and weekend ward rounds to gain feedback and determine patient and nursing staff satisfaction with this innovative system. Questionnaires were handed to all patients and staff nurses involved. Both patients and nursing staff had very positive reactions to the RPRS in an orthopaedic postoperative care setting. Potential uses in orthopaedic surgery include clinical outreach in the setting of trauma, supervision in theatre, or watching theatre cases from outside the hospital, providing both patient and parent reassurance in paediatric orthopaedic cases, and, finally, in the setting of outpatient departments. Integration of the RPRS in an orthopaedic clinical setting has exciting and limitless potential. More so in this era in which it would allow trainees to benefit from teaching and training while also cutting down their in-house time and thus hospitals costs.
Clough, J F M; Veillette, C J H
Finding useful high-grade professional orthopaedic information on the Internet is often difficult. Orthopaedic Web Links (OWL) is a searchable database of vetted online orthopaedic resources. OWL uses a subject directory (OWL Directory) and a custom search engine (OWL Web) to provide a list of resources. The most effective way to find readily accessible, full text on-subject material suitable for education of an orthopaedic surgeon or trainee has not been defined. We therefore (1) proposed a method for selecting topics and evaluating searches and (2) compared the search results from an orthopaedic-specific directory (OWL Directory), a custom search engine (OWL Web), and standard Google searches. A scoring system for evaluation of the search results was developed for standardized comparison. Single words and sets of three words from randomly selected examination questions provided the search strings to compare the three strategies. For single keyword searches, the OWL Directory scored highest (16.4/50) of the three methods. For the three keywords searches, OWL Web had the highest mean score (26.0/50), followed by Google (22.8/50), and the OWL Directory (1.0/50). OWL Web searches had higher scores than Google searches, while returning 800 times fewer search results. The OWL Directory of orthopaedic subjects on the Internet provides a simple browsable category structure to find information. The OWL Web search engine scored higher than Google and resulted in a greater proportion of valid, on-subject, and accessible resources in the search results.
Daniels, Eldra W; French, Keisha; Murphy, Laurie A; Grant, Richard E
Diversity among health professionals is believed to be an important step toward improving patient communication and addressing health disparities. Orthopaedic surgery traditionally has been overly represented by Caucasian males, and it remains one of the least racially and gender-diversified surgical subspecialties. As the US population becomes increasingly diverse, a concomitant increase in ethnic diversity and gender diversity is needed to ensure that all Americans receive high-quality, culturally competent health care. We asked whether (1) representation of female orthopaedic residents and clinical faculty and (2) representation of ethnic minority orthopaedic residents, clinical faculty, and basic science faculty increased during the past 15 years since our original study. A questionnaire, created on SurveyMonkey®, was distributed by email to the coordinators of all 152 orthopaedic residency training programs in the United States. Eighty (53%) responses were received. The percentage of female orthopaedic surgery residents and female clinical faculty has nearly doubled since 1995. The percentages of African American, Asian/Pacific Islander, and Hispanic orthopaedic residents, and of clinical faculty have increased. Orthopaedic basic science research faculty is 83% male and is comprised primarily of Caucasians (62%) and Asian/Pacific Islanders (24%). Despite the increase in diversity in the orthopaedic workforce during the past 15 years, ethnic and gender disparities persist among orthopaedic residency programs regarding residents, clinical faculty, and basic research faculty. To increase diversity in orthopaedic residency programs, an emphasis on recruiting ethnic and gender minority candidates needs to become a priority in the orthopaedic academic community.
Dodwell, Emily; Dua, Shiv; Dulai, Sukhdeep K; Astone, Kristina; Mulpuri, Kishore
The quality of randomized controlled trials (RCTs) in orthopaedics is a topic of considerable importance, as RCTs play a major role in guiding clinical practice. The quality of RCTs published between 1995 and 2005 has previously been documented. The purpose of the current study was to assess and describe the quality of pediatric orthopaedic RCTs published from 2005 to 2012, by identifying study characteristics associated with higher quality and outlining areas for improvement. A standardized literature search was used to identify pediatric orthopaedic RCTs published in 7 well-recognized journals between September 2005 and July 2012 inclusive. The Detsky Quality Assessment Scale and the CONSORT checklist for Non-Pharmacologic Trials were used to assess the quality of the RCTs. Scores for the Detsky and CONSORT were calculated by 2 independent blinded orthopaedic surgeon reviewers with epidemiologic training. Forty RCTs were included in this analysis. The mean percentage score on the Detsky quality scale was 67%. Sixteen (40%) of the articles satisfied the threshold for a satisfactory level of methodological quality (Detsky >75%). Twenty-five (63%) of these studies were negative studies, concluding no difference between treatment arms. In 52% of the negative studies, an a priori sample size analysis was absent, and 28% were self-described as underpowered. In multiple variable regression analysis, only working with a statistician was significantly associated with higher Detsky percentage scores (P=0.01). There is a trend for improving quality in pediatric orthopaedic RCTs. Compared with past reports, the mean Detsky score improved from 53% to 67%, and the proportion meeting an acceptable level of quality improved from 19% to 40%. One of the most concerning findings of this study was the lack of attention to sample size and power analysis, and the potential for underpowered studies. Ongoing efforts are necessary to improve the conduct and reporting of clinical trials
Madry, H; Alini, M; Stoddart, M J; Evans, C; Miclau, T; Steiner, S
Research in orthopaedic tissue engineering has intensified over the last decade and new protocols continue to emerge. The clinical translation of these new applications, however, remains associated with a number of obstacles. This report highlights the major issues that impede the clinical translation of advanced tissue engineering concepts, discusses strategies to overcome these barriers, and examines the need to increase incentives for translational strategies. The statements are based on presentations and discussions held at the AO Foundation-sponsored symposium "Where Science meets Clinics 2013" held at the Congress Center in Davos, Switzerland, in September, 2013. The event organisers convened a diverse group of over one hundred stakeholders involved in clinical translation of orthopaedic tissue engineering, including scientists, clinicians, healthcare industry professionals and regulatory agency representatives. A major point that emerged from the discussions was that there continues to be a critical need for early trans-disciplinary communication and collaboration in the development and execution of research approaches. Equally importantly was the need to address the shortage of sustained funding programs for multidisciplinary teams conducting translational research. Such detailed discussions between experts contribute towards the development of a roadmap to more successfully advance the clinical translation of novel tissue engineering concepts and ultimately improve patient care in orthopaedic and trauma surgery.
Merschin, D; Mutschler, M; Stange, R; Kopschina, C; Schüttrumpf, J P; Doepfer, A K; Achatz, G; Niethard, M; Hoffmann, R; Kladny, B; Perl, M; Münzberg, M
Background: It has been known for several years that orthopaedic and trauma clinics suffer from a shortage of young people, due to the substantial loss in attractiveness. The Youth Forum OU has been addressing this problem for many years, by initiating many projects such as the Summer School to counteract this trend. The purpose of this research is to evaluate the success of Summer Schools since 2009. Methods: The Youth Forum OU performed a survey in December 2014 to answer the research question on the basis of an internet-based poll of the student participants in all Summer Schools between 2009 and 2014. Following data cleansing, 121 students and former students were included in the survey. Results: Seventy-two completed questionnaires were collected and included in the evaluation. The survey included 40 % of Summer School participants, with a mean age of 27.3 years (SD ± 2.95); 50 % were female. Participation in the Summer School helped 50 % of the respondents to decide to start advanced study in orthopaedics and/or traumatology (OU). One third of these Summer School participants had already finished a university degree; 100 % are now residents in orthopaedics and/or traumatology. Regardless of prior plans, 87.2 % of participants are now residents in OU. Thirty-three are still students: 78.8 % have already decided to work in OU. The survey also served to identify the factors positively and negatively associated with OU. Unfavourable factors included the reputation of OU, and the difficulty of reconciling family and work. Favourable factors included surgical work and personal experience during university studies. Discussion: The aim of this study was to evaluate whether the efforts of the Youth Forum OU, the German Society for Orthopaedics and Traumatology (DGOU) and the local hospitals lead to increased interest in OU. The answer to this question is positive. This is particularly true for those students who did not plan to become an orthopaedic or
Poole, Daniele; Chieregato, Arturo; Langer, Martin; Viaggi, Bruno; Cingolani, Emiliano; Malacarne, Paolo; Mengoli, Francesca; Nardi, Giuseppe; Nascimben, Ennio; Riccioni, Luigi; Turriziani, Ilaria; Volpi, Annalisa; Coniglio, Carlo; Gordini, Giovanni
Background Antibiotic prophylaxis is frequently administered in severe trauma. However, the risk of selecting resistant bacteria, a major issue especially in critical care environments, has not been sufficiently investigated. The aim of the present study was to provide guidelines for antibiotic prophylaxis for four different trauma-related clinical conditions, taking into account the risks of antibiotic-resistant bacteria selection, thus innovating previous guidelines in the field. Methods The MEDLINE database was searched for studies comparing antibiotic prophylaxis to controls (placebo or no antibiotic administration) in four clinical traumatic conditions that were selected on the basis of the traumatic event frequency and/or infection severity. The selected studies focused on the prevention of early ventilator associated pneumonia (VAP) in comatose patients with traumatic brain injury, of meningitis in severe basilar skull fractures, of wound infections in long-bone open fractures. Since no placebo-controlled study was available for deep surgical site-infections prevention in abdominal trauma with enteric contamination, we compared 24-hour and 5-day antibiotic prophylaxis policies. A separate specific research focused on the question of antibiotic-resistant bacteria selection caused by antibiotic prophylaxis, an issue not adequately investigated by the selected studies. Randomised trials, reviews, meta-analyses, observational studies were included. Data extraction was carried out by one author according to a predefined protocol, using an electronic form. The strength of evidence was stratified and recommendations were given according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Results Uncertain evidence deserving further studies was found for two-dose antibiotic prophylaxis for early VAP prevention in comatose patients. In the other cases the risk of resistant-bacteria selection caused by antibiotic administration
Mehlman, Charles T; Okike, Kanu; Bhandari, Mohit; Kocher, Mininder S
The practice of medicine is based on evidence from peer-reviewed literature. As can occur with author-related funding, the integrity of the process by which manuscripts are reviewed, edited, and approved for publication may be at risk due to financial conflict of interest. The purpose of our study was to assess potential financial conflict of interest among physician editorial board members of orthopaedic surgery journals. We identified the physician editorial board members of 15 orthopaedic surgery journals and searched the 2014 payments that were archived in the Centers for Medicare & Medicaid Services Open Payments system (mandated by the Physician Payments Sunshine Act). Total dollar values were calculated and tabulated in a multilevel fashion: nothing reported, >$0 and ≤$10,000, >$10,000, >$250,000, and >$950,000. We identified 908 physician editors of 15 orthopaedic surgery journals. Something of financial value was received by 78% (712 of 908) of these individuals. Rates of editorial board potential financial conflict of interest for individual journals ranged from 4% to 73% in the >$10,000 category. At the >$250,000 mark, rates ranged from 0% (2 journals) to 31%. When applying the >$950,000 criterion, physician potential conflict of interest ranged from 0% (5 journals) to 13%. Editor-related potential financial conflicts of interest exist in the orthopaedic surgery journals that we analyzed. These potential financial conflicts could possibly impact reviews.
Tennent, David J; Bailey, James R; Ficke, James R; Stinner, Daniel J
The clinical application of evidence-based medicine is influenced by the quality of the published literature. Journals assign objective levels of evidence to articles to describe the quality and reliability of individual articles. Studies assigned levels I to III are considered higher quality studies. This study reviewed 60 continuous years of the American edition of the Journal of Bone and Joint Surgery to analyze trends in the quality of research published by U.S. military orthopaedic surgeons. Three hundred and six of 371 identified articles were assigned a level of evidence from I to V. These were then analyzed to determine if military orthopaedic surgeons were producing higher quality studies over time. Over time, the total number of articles published decreased. However, the number of higher quality studies and average level of evidence per decade improved over time. This trend toward publishing higher quality studies is consistent with the general orthopaedic community and highlights the need for continued work by the military orthopaedic community to conduct higher quality studies.
Althausen, Peter L
The development of a busy community-based trauma practice is a multifaceted endeavor that requires good clinical judgment, business acumen, interpersonal skills, and negotiation tactics. Private practice is a world in which perfect outcomes are expected and efficiency is paramount. Successful operative outcomes are dependent on solid clinical training, good preoperative planning, and communication with mentors when necessary. Private practitioners must display confidence, polite behavior, and promptness. Maintaining availability for consultation from emergency room physicians, private practice physicians, and local orthopaedic surgeons is a powerful marketing tool. Orthopaedic trauma surgery has been shown to be a profitable field for hospitals and private practitioners. However, physician success depends on a sound understanding of hospital finance, marketing skills, and knowledge of billing and coding. As the financial pressures of medical care increase, hospital negotiation will be paramount, and private practitioners must combine clinical and business skills to provide good patient care while maintaining independence and financial security.
Kleine-Konig, Marie-Theres; Schulte, Tobias L; Gosheger, Georg; Rödl, Robert; Schiedel, Frank M
The quality of the abstracts presented at a conference reflects the scientific work and level of activity of the scientific association concerned. The aim of the present study was to determine the rate of publications of podium presentations and posters at the conferences of the European Paediatric Orthopaedic Society (EPOS) from 2006 to 2008 and to identify factors that favor publication in peer-reviewed journals. The results are compared with those of other international societies. All 646 abstracts (including podiums, posters, and e-posters) presented at the EPOS conferences were investigated using the PubMed database to identify any corresponding published articles in the journals listed in the database. A period of 5 years before and after the relevant conference was used for the PubMed search. Factors influencing publication and the quality of the study, such as the type of presentation and the level of evidence, were also investigated. A publication rate of 36.7% was observed, corresponding to 237 publications of 646 abstracts. The period to publication showed a mean of 13.88 ± 1.34 months. It was found that abstracts of podium presentations were published significantly more often than poster abstracts (P<0.001). Experimental studies, with a publication rate of 50.9%, showed better results than clinical studies (36.0%). Overall, the articles were published in 61 different journals, with the largest number (n=50) appearing in the Journal of Pediatric Orthopaedics. In addition, the present study shows that abstracts with a higher level of evidence were associated with a higher publication rate. At 36.7%, the rate of publication of EPOS abstracts is within the range reached by other specialist orthopaedics societies, such as the German Society of Orthopaedics and Trauma Surgery (36%) and the British Orthopaedic Association (36%). However, it is lower than the publication rate of the Pediatric Orthopaedic Society of North America (POSNA), at 50%. The high
Kiesau, Carter D; Heim, Kathryn A; Parekh, Selene G
Leadership and business challenges have become increasingly present in the practice of medicine. Orthopaedic residency programs are at the forefront of educating and preparing orthopaedic surgeons. This study attempts to quantify the number of orthopaedic residency programs in the United States that include leadership or business topics in resident education program and to determine which topics are being taught and rate the importance of various leadership characteristics and business topics. A survey was sent to all orthopaedic department chairpersons and residency program directors in the United States via e-mail. The survey responses were collected using a survey collection website. The respondents rated the importance of leadership training for residents as somewhat important. The quality of character, integrity, and honesty received the highest average rating among 19 different qualities of good leaders in orthopaedics. The inclusion of business training in resident education was also rated as somewhat important. The topic of billing and coding received the highest average rating among 14 different orthopaedically relevant business topics. A variety of topics beyond the scope of clinical practice must be included in orthopaedic residency educational curricula. The decreased participation of newly trained orthopaedic surgeons in leadership positions and national and state orthopaedic organizations is concerning for the future of orthopaedic surgery. Increased inclusion of leadership and business training in resident education is important to better prepare trainees for the future.
Wongwaisayawan, Sirote; Suwannanon, Ruedeekorn; Prachanukool, Thidathit; Sricharoen, Pungkava; Saksobhavivat, Nitima; Kaewlai, Rathachai
Ultrasound plays a pivotal role in the evaluation of acute trauma patients through the use of multi-site scanning encompassing abdominal, cardiothoracic, vascular and skeletal scans. In a high-speed polytrauma setting, because exsanguinations are the primary cause of trauma morbidity and mortality, ultrasound is used for quick and accurate detection of hemorrhages in the pericardial, pleural, and peritoneal cavities during the primary Advanced Trauma Life Support (ATLS) survey. Volume status can be assessed non-invasively with ultrasound of the inferior vena cava (IVC), which is a useful tool in the initial phase and follow-up evaluations. Pneumothorax can also be quickly detected with ultrasound. During the secondary survey and in patients sustaining low-speed or localized trauma, ultrasound can be used to help detect abdominal organ injuries. This is particularly helpful in patients in whom hemoperitoneum is not identified on an initial scan because findings of organ injuries will expedite the next test, often computed tomography (CT). Moreover, ultrasound can assist in detection of fractures easily obscured on radiography, such as rib and sternal fractures.
Cross, Michael Brian; Yi, Paul Hyunsoo; Thomas, Charlotte F; Garcia, Jane; Della Valle, Craig J
Malnutrition can increase the risk of surgical site infection in both elective spine surgery and total joint arthroplasty. Obesity and diabetes are common comorbid conditions in patients who are malnourished. Despite the relatively high incidence of nutritional disorders among patients undergoing elective orthopaedic surgery, the evaluation and management of malnutrition is not generally well understood by practicing orthopaedic surgeons. Serologic parameters such as total lymphocyte count, albumin level, prealbumin level, and transferrin level have all been used as markers for nutrition status. In addition, anthropometric measurements, such as calf and arm muscle circumference or triceps skinfold, and standardized scoring systems, such as the Rainey-MacDonald nutritional index, the Mini Nutritional Assessment, and institution-specific nutritional scoring tools, are useful to define malnutrition. Preoperative nutrition assessment and optimization of nutritional parameters, including tight glucose control, normalization of serum albumin, and safe weight loss, may reduce the risk of perioperative complications, including infection.
Weinhardt, Janice; Jacobson, Kristine
A growing elderly population with an increasing number of comorbidities is presenting for orthopaedic procedures and interventions, lending themselves to greater risk for complications, including stroke. Prior stroke or transient ischemic attack, hypertension, diabetes mellitus, atrial fibrillation, carotid stenosis, and advanced age are the most common risk factors for perioperative stroke. A comprehensive neurologic assessment should include a thorough history including identification of risk factors, pertinent medications, and a physical examination. This assessment is important to establish a baseline for subsequent neurologic evaluations in the postoperative period. Neurologic physical assessment can be an intimidating task, especially for the orthopaedic nurse who lacks experience in caring for the neurologic patient. Patients who are found with a focal neurologic deficit that is suspicious for stroke require urgent assessment, exclusion of stroke mimics, and activation of the institution's stroke team to allow for brain saving interventions. Time is brain.
Roberts, Timothy T; Haines, Colin M; Uhl, Richard L
Allergic or hypersensitivity reactions to orthopaedic implants can pose diagnostic and therapeutic challenges. Although 10% to 15% of the population exhibits cutaneous sensitivity to metals, deep-tissue reactions to metal implants are comparatively rare. Nevertheless, the link between cutaneous sensitivity and clinically relevant deep-tissue reactions is unclear. Most reactions to orthopaedic devices are type IV, or delayed-type hypersensitivity reactions. The most commonly implicated allergens are nickel, cobalt, and chromium; however, reactions to nonmetal compounds, such as polymethyl methacrylate, antibiotic spacers, and suture materials, have also been reported. Symptoms of hypersensitivity to implants are nonspecific and include pain, swelling, stiffness, and localized skin reactions. Following arthroplasty, internal fixation, or implantation of similarly allergenic devices, the persistence or early reappearance of inflammatory symptoms should raise suspicions for hypersensitivity. However, hypersensitivity is a diagnosis of exclusion. Infection, as well as aseptic loosening, particulate synovitis, instability, and other causes of failure must first be eliminated.
Bohl, Daniel D; Singh, Kern; Grauer, Jonathan N
The use of nationwide databases to conduct orthopaedic research has expanded markedly in recent years. Nationwide databases offer large sample sizes, sampling of patients who are representative of the country as a whole, and data that enable investigation of trends over time. The most common use of nationwide databases is to study the occurrence of postoperative adverse events. Other uses include the analysis of costs and the investigation of critical hospital metrics, such as length of stay and readmission rates. Although nationwide databases are powerful research tools, readers should be aware of the differences between them and their limitations. These include variations and potential inaccuracies in data collection, imperfections in patient sampling, insufficient postoperative follow-up, and lack of orthopaedic-specific outcomes.
Mauffrey, Cyril; Scarlat, Marius M; Pećina, Marko
Once the privilege of few clinical scholars in the field of orthopaedics, medical writing has become a must for career advancement. The number of papers submitted and published yearly has increased steadily, and with the development of the Internet, manuscript and journals have become easily accessible. Medical writing has risen to become a discipline in itself, with rules and standards. However, heterogeneity in the quality of papers submitted still prevails, with large variations in both form and content. With countries such as China and India submitting an exponential number of manuscripts, it is important and helpful that standards of medical writing be emphasised to help writers who do not always have the required support to produce an outstanding manuscript. In this paper, we summarise what may become standards for medical writing in the field of orthopaedics.
Nandi, Sumon; Cho, Samuel K; Freedman, Brett A; Firoozabadi, Reza
The American Orthopaedic Association-Japanese Orthopaedic Association (AOA-JOA) Traveling Fellowship, which began in 1992 as a collaborative effort between the 2 orthopaedic communities, is aimed at fostering leadership among early-career surgeons through clinical, academic, and cultural exchange. Over 3 weeks, we experienced an extraordinary journey that led us across nearly 800 miles of the picturesque Japanese countryside, with stops at 6 distinguished academic centers. The opportunity to become personally acquainted with orthopaedic leaders in Japan, learn from their experiences, and immerse ourselves in the ancient and storied culture of a beautiful country was one that we will not soon forget. Along the way, we accumulated a wealth of information while enjoying the legendary hospitality of the Japanese people. There is a ubiquitous challenge in delivering cost-effective, accessible health care while maintaining a commitment to education and research. The U.S. orthopaedic community may take solace in the fact that our Japanese colleagues stand with us as partners in this pursuit, and our relationship with them continues to grow stronger through endeavors such as the AOA-JOA Traveling Fellowship. We look forward to honoring our Japanese colleagues in 2017 when we host them in the United States.
Torretti, Joel A; Sengupta, Dilip K
Cervical spine trauma is a common problem with a wide range of severity from minor ligamentous injury to frank osteo-ligamentous instability with spinal cord injury. The emergent evaluation of patients at risk relies on standardized clinical and radiographic protocols to identify injuries; elucidate associated pathology; classify injuries; and predict instability, treatment and outcomes. The unique anatomy of each region of the cervical spine demands a review of each segment individually. This article examines both upper cervical spine injuries, as well as subaxial spine trauma. The purpose of this article is to provide a review of the broad topic of cervical spine trauma with reference to the classic literature, as well as to summarize all recently available literature on each topic. Identification of References for Inclusion: A Pubmed and Ovid search was performed for each topic in the review to identify recently published articles relevant to the review. In addition prior reviews and classic references were evaluated individually for inclusion of classic papers, classifications and previously unidentified references. PMID:21139776
Behravesh, E; Yasko, A W; Engel, P S; Mikos, A G
Synthetic biodegradable polymers offer an alternative to the use of autografts, allografts, and nondegradable materials for bone replacement. They can be synthesized with tailored mechanical and degradative properties. They also can be processed to porous scaffolds with desired pore morphologic features conducive to tissue ingrowth. Moreover, functionalized polymers can modulate cellular function and induce tissue ingrowth. This review focuses on four classes of polymers that hold promise for orthopaedic applications: poly alpha-hydroxy esters, polyphosphazenes, polyanhydrides, and polypropylene fumarate crosslinked networks.
Lefaivre, Kelly A; Shadgan, Babak; O'Brien, Peter J
Citation analysis reflects the recognition a work has received in the scientific community by its peers, and is a common method to determine 'classic' works in medical specialties. We determined which published articles in orthopaedic journals have been most cited by other authors by ranking the 100 top-cited works. By analyzing characteristics of these articles, we intended to determine what qualities make an orthopaedic article important to the specialty. Finally, we determined if there was a change in level of evidence of studies on this list with time. Science Citation Index Expanded was searched for citations to articles published in any of the 49 journals in the subject category "ORTHOPEDICS." Each of the 49 journals was searched separately using the "cited reference search" to determine the 100 most often cited articles. Each article was reviewed for basic information including year of publication, country of origin, source journal of the article, article type, and level of evidence. We categorized the journal article by field of research where possible. The number of citations ranged from 1748 to 353. The 100 most often cited articles in orthopaedic surgery were published in 11 of the 49 journals, spanning from general to more specific subspecialty journals. The majority of the papers (76) were clinical, with the remaining representing some type of basic science research. The most common level of evidence was IV (42 of the 76 studies). Of the 76 clinical articles, 27 introduced or tested classification systems or outcome measurement tools. Authors aiming to write a highly cited article in an orthopaedic surgery journal will be favored by language of publication, source journal, country of origin, and introduction of a classification scheme or outcome tool.
Fingerhut, A; Boffard, K D
Trauma societies have an influence on the management and outcome of polytrauma. Its contributions include setting up standard definitions, trauma registries, evidence-based medicine guidelines, and the creation of educational tools such as specific courses of trauma care and decision-making. Literature and web-based search of definitions and available information. The history of and accomplishments of trauma societies in the above-mentioned domains are reviewed, including the major trauma registries (Major Trauma Outcome Study, National Trauma Data Bank, The American Pediatric Surgical Association, the American Burn Association trauma, and the German Trauma Society trauma registries). Several learned societies in the field of trauma have created recommendations and/or guidelines concerning polytrauma (the Eastern Association for the Surgery of Trauma, The Society of Critical Care Medicine, and the German Trauma Society, Brain Trauma Foundation, and the Essential Trauma Care (EsTC) Guidelines). Several practical, hands-on courses and scoring systems for improving the quality of management of polytrauma patients have been founded and implemented in the past 35 years, including the Advanced Trauma Life Support (ATLS(®)) Course of the American College of Surgeons, the Definitive Surgical Trauma Care (DSTC(TM)) Course, the National Trauma Management Course (NTMC(TM) Course,) the Advanced Trauma Operative Management (ATOM) Course, and the European Trauma Course (ETC). Trauma and emergency care societies have made an elaborate, substantial contribution by developing trauma registries and creating specific guidelines courses on trauma care and decision-making.
Pierce, Read G; Bozic, Kevin J; Bradford, David S
In recent decades American medicine has undergone tremendous changes. Numerous reimbursement and systems approaches to controlling medical inflation and improving quality have failed to provide cost-effective, high-quality health care in most circumstances. Public and private payers are currently implementing pay for performance, a new reimbursement method linking physician pay to evidence of adherence to performance measures, to constrain costs, encourage efficiency, and maximize value for health care dollars. High-quality research regarding pay for performance and its impact is scarce, particularly in orthopaedic surgery. Although supporters argue pay for performance will remedy the fragmented, costly delivery of health services in the United States, skeptics raise concerns about disagreement over quality guidelines, financial implications for providers and hospitals, inadequate infrastructure, public reporting, system gaming, and physician support. Our survey of orthopaedic surgeons reveals limited understanding of pay for performance, marked skepticism of nonphysician stakeholders' intentions, and a strong desire for greater clinician involvement in shaping the pay for performance movement. As pay for performance will likely be a long-term change that will have an impact on every orthopaedic surgeon, clinician awareness and participation will be fundamental in creating successful pay for performance programs.
Moraleda, L; Castellote, M
The aim of this study was to identify the commonest referrals to a paediatric orthopaedic outpatient clinic and, therefore, to be able to improve the paediatric residency program in managing musculoskeletal problems. Demographic data, referrals and final diagnosis were collected prospectively on all patients that were evaluated in a paediatric orthopaedic outpatient clinic. The majority of referrals were to evaluate musculoskeletal pain (37%), foot deformity (20%), spine deformity (15%), walking pattern (11%), alignment of the lower limbs (4%), and development of the hip (4%). A normal physical examination or a normal variation was observed in 42% of patients. A mild condition was observed in 17% of patients that should have only been referred to a paediatric orthopaedic clinic after failing to resolve pain with anti-inflammatories or physiotherapy. A mild deformity that only needed treatment if it became symptomatic was seen in 8% of patients. The majority of referrals were due to a normal variation or mild conditions that only required symptomatic treatment. Paediatric residency programs do not reflect the prevalence of musculoskeletal conditions in clinical practice. Copyright © 2014 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.
Rangan, A; Jefferson, L; Baker, P; Cook, L
The aim of this study was to review the role of clinical trial networks in orthopaedic surgery. A total of two electronic databases (MEDLINE and EMBASE) were searched from inception to September 2013 with no language restrictions. Articles related to randomised controlled trials (RCTs), research networks and orthopaedic research, were identified and reviewed. The usefulness of trainee-led research collaborations is reported and our knowledge of current clinical trial infrastructure further supplements the review. Searching yielded 818 titles and abstracts, of which 12 were suitable for this review. Results are summarised and presented narratively under the following headings: 1) identifying clinically relevant research questions; 2) education and training; 3) conduct of multicentre RCTs and 4) dissemination and adoption of trial results. This review confirms growing international awareness of the important role research networks play in supporting trials in orthopaedic surgery. Multidisciplinary collaboration and adequate investment in trial infrastructure are crucial for successful delivery of RCTs. Cite this article: Bone Joint Res 2014;3:169-74. ©2014 The British Editorial Society of Bone & Joint Surgery.
Clarke, Nicholas M P; Page, Jonathan E
At the turn of the last century, rickets (vitamin D deficiency) was one of the most common musculoskeletal diseases of the paediatric population presenting to physicians. Today, the most common referral pathway for these patients ends in a paediatric orthopaedic outpatient clinic. Vitamin D deficiency is a clinical entity that can affect all children and should be looked for in all children with musculoskeletal symptoms. The child at risk of rickets is now white, breastfed, protected from the sun and obese. Vitamin D deficiency can present as atypical muscular pain, pathological fractures or slipped upper femoral epiphysis. Obesity is linked with lower vitamin D levels; however, in the paediatric population, this does not necessarily equal clinical disorder. Vitamin D supplements can be used to reduce the risk of pathological fractures in the cerebral palsy child. It should also form part of the differential diagnosis in the work-up of nonaccidental injuries. Children with a low vitamin D present with a higher incidence of fractures from normal activities. Vitamin D levels need to be assessed before any form of orthopaedic surgery, as it can affect growth, both in the diaphysis of the bone and in the growth plate. Vitamin D levels are a key element in the successful practice of paediatric orthopaedics. It is not just the possible cause of disorder presenting to the clinician but also extremely important in ensuring the successful postoperative recovery of the patient.
Hansen, Erik; Bozic, Kevin J
The US healthcare system is currently facing daunting demographic and economic challenges. Because musculoskeletal disorders and disease represent a substantial and growing portion of this healthcare burden, novel approaches will be needed to continue to provide high-quality, affordable, and accessible orthopaedic care to our population. The concept of "disruptive innovations," which has been studied and popularized by Harvard Business School Professor Clayton Christensen, may offer a potential framework for developing strategies to improve quality and control costs associated with musculoskeletal care. The introduction of mobile fluoroscopic imaging systems, the development of the Surgical Implant Generation Network intramedullary nail for treatment of long bone fractures in the developing world, the expanding role and contributions of physician assistants and nurse practitioners to the orthopaedic team, and the rise of ambulatory surgery centers are all examples of disruptive innovations in the field of orthopaedics. Although numerous cultural and regulatory barriers have limited the widespread adoption of these "disruptive innovations," we believe they represent an opportunity for clinicians to regain leadership in health care while at the same time improving quality and access to care for patients with musculoskeletal disease.
Feghhi, Daniel P; Komlos, Daniel; Agarwal, Nitin; Sabharwal, Sanjeev
Increased availability of medical information on the Internet empowers patients to look up answers to questions about their medical conditions. However, the quality of medical information available on the Internet is highly variable. Various tools for the assessment of online medical information have been developed and used to assess the quality and accuracy of medical web sites. In this study we used the LIDA tool (Minervation) to assess the quality of pediatric patient information on the AAOS (American Academy of Orthopaedic Surgeons) and POSNA (Pediatric Orthopaedic Society of North America) web sites. The accessibility, usability, and reliability of online medical information in the "Children" section of the AAOS web site and on the POSNA web site were assessed with use of the LIDA tool. Flesch-Kincaid (FK) and Flesch Reading Ease (FRE) values were also calculated to assess the readability of the pediatric education material. Patient education materials on each web site scored in the moderate range in assessments of accessibility, usability, and reliability. FK and FRE values indicated that the readability of each web site remained at a somewhat higher (more difficult) level than the recommended benchmark. The quality and readability of online information for children on the AAOS and POSNA web sites are acceptable but can be improved further. The quality of online pediatric orthopaedic patient education materials may affect communication with patients and their caregivers, and further investigation and modification of quality are needed. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.
Evans, C.H.; Ghivizzani, S.C.; Robbins, P.D.
Orthopaedic gene therapy has been the topic of considerable research for two decades. The preclinical data are impressive and many orthopaedic conditions are well suited to genetic therapies. But there have been few clinical trials and no FDA-approved product exists. This paper examines why this is so. The reasons are multifactorial. Clinical translation is expensive and difficult to fund by traditional academic routes. Because gene therapy is viewed as unsafe and risky, it does not attract major funding from the pharmaceutical industry. Start-up companies are burdened by the complex intellectual property environment and difficulties in dealing with the technology transfer offices of major universities. Successful translation requires close interactions between scientists, clinicians and experts in regulatory and compliance issues. It is difficult to create such a favourable translational environment. Other promising fields of biological therapy have contemplated similar frustrations approximately 20 years after their founding, so there seem to be more general constraints on translation that are difficult to define. Gene therapy has noted some major clinical successes in recent years, and a sense of optimism is returning to the field. We hope that orthopaedic applications will benefit collaterally from this upswing and move expeditiously into advanced clinical trials. PMID:21948071
Zelle, Boris A; Weathers, Michael A; Fajardo, Roberto J; Haghshenas, Varan; Bhandari, Mohit
As academic leaders, orthopaedic chairs represent role models for scholarly activities. Despite the importance of journal publications as a measure of scholarly activity, data on the publication productivity of orthopaedic chairs remain limited. The goals of this study were to record the publication productivity of orthopaedic chairs and evaluate the extent to which they maintained their scholarly activity while serving as chairs. The chairs of all orthopaedic residency programs in the United States were identified through the Accreditation Council for Graduate Medical Education (ACGME) web site, and were confirmed by information found on the web site of each orthopaedic program that was included in the study. University and non-university chairs were defined based on affiliation of the program with a medical school. The publication records of the program chairs were retrieved through the Scopus database. During the 7 years prior to their appointment to chair, the mean number of total publications was significantly higher for university chairs (n = 58.6, range 0 to 217) than for non-university chairs (n = 29.1, range 0 to 13) (p = 0.003). The mean number of publications per year during the 7 years leading up to the chair position was 4.66 (range, 0 to 25) for the university chairs, and 2.29 (range, 0 to 10.9) for the non-university group (p = 0.02). While serving as chair, the mean number of publications per year significantly decreased among the university chairs to 3.75 (range, 0 to 32.8; p = 0.015), whereas no significant change was observed among non-university chairs. The mean percentage of first authorships was not significantly different between university and non-university chairs. Both groups showed significant declines in first authorships while serving as chair. At the time of becoming chair, the average university chair had published approximately 60 manuscripts, whereas the average non-university chair had published approximately 30 manuscripts. While
Hilibrand, Alan S; Spindler, Kurt; O'Keefe, Regis J
Orthopaedic surgery is expensive and will be carefully scrutinized in the U.S. under health-care reform. Unfortunately, although the orthopaedic literature is replete with clinical outcomes studies, there is still a paucity of meaningful clinical outcomes data that are free from bias. It is possible that orthopaedic procedures may be among the most cost-effective medical treatments for the aging population. However, it is only through the collection of patient-generated outcomes data in prospective randomized and observational studies that orthopaedic surgery can be shown to provide high value (defined as high-quality outcomes at a relatively low cost) to society.The burden of musculoskeletal disease in the U.S. is high; nearly half of all adults describe themselves as having a chronic musculoskeletal condition, and approximately one-quarter of all health-care dollars are spent treating musculoskeletal disease. For this reason, treatment for osteoarthritis, the costliest condition in the elderly population, has drawn great scrutiny from insurers and the government. In the absence of clinical outcomes data that prove the value of orthopaedic interventions, there will be pressure to reduce payments or even deny treatments for these conditions if they are perceived to be too expensive or lack outcomes data supporting their use.Multicenter trials are expensive; this paper analyzes challenges to, and opportunities for, funding. Although National Institutes of Health (NIH) funding has dropped nearly 20% over the past ten years in inflation-adjusted dollars, it has begun a gradual reorientation toward clinical research, which comprised almost 50% of its budget in 2013. The Patient Protection and Affordable Care Act focused more attention on clinical outcomes research, with the establishment of the Patient-Centered Outcomes Research Institute (PCORI), which will ultimately fund $750 million of comparative effectiveness research annually. Another new funding source within
Kesavachandran, Chandrasekharan Nair; Haamann, Frank; Nienhaus, Albert
Various procedures, especially minimal invasive techniques using fluoroscopy, pose a risk of radiation exposure to orthopaedic staff. Anatomical sites such as the eyes, thyroid glands and hands are more vulnerable to radiation considering the limited use of personal protective devices in the workplace. The objective of the study is to assess the annual mean cumulative and per procedure radiation dose received at anatomical locations like eyes, thyroid glands and hands in orthopaedic staff using systematic review. The review of literature was conducted using systematic search of the database sources like PUBMED and EMBASE using appropriate keywords. The eligibility criteria and the data extraction of literature were based on study design (cohort or cross-sectional study), study population (orthopaedic surgeons or their assistants), exposure (doses of workplace radiation exposure at hands/fingers, eye/forehead, neck/thyroid), language (German and English). The literature search was conducted using a PRISMA checklist and flow chart. Forty-two articles were found eligible and included for the review. The results show that radiation doses for the anatomical locations of eye, thyroid gland and hands were lower than the dose levels recommended. But there is a considerable variation of radiation dose received at all three anatomical locations mainly due to different situations including procedures (open and minimally invasive), work experience (junior and senior surgeons),distance from the primary and secondary radiation, and use of personal protective equipments (PPEs). The surgeons receive higher radiation dose during minimally invasive procedures compared to open procedures. Junior surgeons are at higher risk of radiation exposure compared to seniors. PPEs play a significant role in reduction of radiation dose. Although the current radiation precautions appear to be adequate based on the low dose radiation, more in-depth studies are required on the variations of
Stenhouse, N; Gallannaugh, S C
An Orthopaedic Surgeon's Assistant has been part of the orthopaedic surgical team at Hastings since 1983. Having a suitably trained person in post ensures continuity and stability and enhances the treatment of patients, the performance of the department and the training offered to Higher Surgical Trainees. Discussion includes the value of such a role, other orthopaedic models and the need for a nationally accredited training scheme and qualification.
Gopinathan, Nirmal Raj; Santhanam, Siva Swaminathan; Saibaba, Balaji; Dhillon, Mandeep Singh
Background: Vascular trauma associated with bony injuries is an orthopaedic emergency. Lack of timely intervention can lead to loss of limb or even life. Inspite of the rising incidence of high speed road traffic accidents in India, there is paucity of literature regarding the demographic pattern, clinical morbidity, management strategies and outcome of arterial injuries associated with lower limb trauma. The aim of this study is to describe the epidemiology and outcome of lower extremity musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India. Materials and Methods: All individuals who presented to our tertiary care trauma center from July 2013 to December 2014 with lower extremity vascular injury associated with lower limb fractures were identified from a retrospective trauma database for this descriptive study. For the 17 months, there were 82 lower extremity vascular trauma cases admitted in our trauma center, of which 50 cases were included in the study. 32 patients with crush injuries, traumatic amputations, and those with head injury and blunt trauma to chest or abdomen were excluded from the study. Results: Out of the 50 cases of lower extremity vascular injury with associated lower limb fractures, 19 limbs were salvaged, 28 amputated, and three patients expired. Young males in the age group of 20–39 years were frequently injured. Motor vehicle accident (MVA) (82%) was found to be the most common cause followed by pedestrian injury. Popliteal artery (62%) was the most common vessel injured, followed by femoral artery (28%). The salvageability percentage was much higher (64%) in the femoral artery injury group when compared to popliteal artery injury group (25%). There were 32 open fractures, with amputation rates (60%) being higher and all three cases of death falling in this group. In addition, the limb salvageability percentage was 43.2% when the patient presented within 12 h of injury and this decreased to a mere
Gopinathan, Nirmal Raj; Santhanam, Siva Swaminathan; Saibaba, Balaji; Dhillon, Mandeep Singh
Vascular trauma associated with bony injuries is an orthopaedic emergency. Lack of timely intervention can lead to loss of limb or even life. Inspite of the rising incidence of high speed road traffic accidents in India, there is paucity of literature regarding the demographic pattern, clinical morbidity, management strategies and outcome of arterial injuries associated with lower limb trauma. The aim of this study is to describe the epidemiology and outcome of lower extremity musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India. All individuals who presented to our tertiary care trauma center from July 2013 to December 2014 with lower extremity vascular injury associated with lower limb fractures were identified from a retrospective trauma database for this descriptive study. For the 17 months, there were 82 lower extremity vascular trauma cases admitted in our trauma center, of which 50 cases were included in the study. 32 patients with crush injuries, traumatic amputations, and those with head injury and blunt trauma to chest or abdomen were excluded from the study. Out of the 50 cases of lower extremity vascular injury with associated lower limb fractures, 19 limbs were salvaged, 28 amputated, and three patients expired. Young males in the age group of 20-39 years were frequently injured. Motor vehicle accident (MVA) (82%) was found to be the most common cause followed by pedestrian injury. Popliteal artery (62%) was the most common vessel injured, followed by femoral artery (28%). The salvageability percentage was much higher (64%) in the femoral artery injury group when compared to popliteal artery injury group (25%). There were 32 open fractures, with amputation rates (60%) being higher and all three cases of death falling in this group. In addition, the limb salvageability percentage was 43.2% when the patient presented within 12 h of injury and this decreased to a mere 16.7% when the patient had presented more than
Budassi, S A
For any patient with obvious or suspected chest trauma, one must first assure an adequate airway and adequate ventilation. One should never hesitate to administer oxygen to a victim with a chest injury. The nurse should be concerned with adequate circulation--this may mean the administration of intravenous fluids, specifically volume expanders, via large-bore cannulae. Any obvious open chest wound should be sealed, and any fractures should be splinted. These patients should be rapidly transported to the nearest Emergency Department capable of handling this type of injury. The majority of patients who arrive in the Emergency Department following blunt or penetrating trauma should be considered to be in critical condition until proven otherwise. On presentation, it is essential to recognize those signs, symptoms, and laboratory values that identify the patient's condition as life-threatening. Simple recognition of these signs and symptoms and early appropriate intervention may alter an otherwise fatal outcome.
Abou Ali, Adham N.; Salem, Karim M.; Alarcon, Louis H.; Bauza, Graciela; Pikoulis, Emmanuel; Chaer, Rabih A.; Avgerinos, Efthymios D.
Experience with temporary intravascular shunts (TIVS) for vessel injury comes from the military sector and while the indications might be clear in geographically isolated and under resourced war zones, this may be an uncommon scenario in civilian trauma. Data supporting TIVS use in civilian trauma have been extrapolated from the military literature where it demonstrated improved life and limb salvage. Few non-comparative studies from the civilian literature have also revealed similar favorable outcomes. Still, TIVS placement in civilian vascular injuries is uncommon and by some debatable given the absence of clear indications for placement, the potential for TIVS-related complications, the widespread resources for immediate and definitive vascular repair, and the need for curtailing costs and optimizing resources. This article reviews the current evidence and the role of TIVS in contemporary civilian trauma management. PMID:28775985
Wang, Jianfeng; Guo, Jing; Liu, Jingsong; Wei, Limin; Wu, Gang
The loss of bone integrity can significantly compromise the aesthetics and mobility of patients and can be treated using orthopaedic implants. Over the past decades; various orthopaedic implants; such as allografts; xenografts and synthetic materials; have been developed and widely used in clinical practice. However; most of these materials lack intrinsic osteoinductivity and thus cannot induce bone formation. Consequently; osteoinductive functionalisation of orthopaedic implants is needed to promote local osteogenesis and implant osteointegration. For this purpose; bone morphogenetic protein (BMP)-functionalised coatings have proven to be a simple and effective strategy. In this review; we summarise the current knowledge and recent advances regardingBMP-functionalised coatings for orthopaedic implants. PMID:24914764
Morgan, Jeffrey; Walker, Shaka; Melaas, David; Crane, Maria; Bacahui, Jacob; Boedeker, Ben H
Telemedicine is the provision of medical care over long distances by way of videoconferencing and other communication technologies. Staff at Vilseck U.S. Army Clinic set up a 3-month pilot real-time tele-orthopaedic clinic to determine if it was feasible to extend Orthopaedic specialty care over long distances. A full time physician assistant was located at the patient site and an orthopaedic surgeon was located at the Landstuhl or Heidelberg site. Patients were initially evaluated by the PA. Complex consults were reviewed by the PA and Orthopaedic surgeon via telephone or VTC. Patients meeting possible indications for surgery were then scheduled for a VTC consult with a surgeon.
Olynik, Christopher R; Gray, Austin; Sinada, Ghassan G
Dentoalveolar injuries are an important and common component of craniomaxillofacial trauma. The dentition serves as a vertical buttress of the face and fractures to this area may result in malalignment of facial subunits. Furthermore, the dentition is succedaneous with 3 phases-primary dentition, mixed dentition, and permanent dentition-mandating different treatment protocols. This article is written for nondental providers to diagnose and treat dentoalveolar injuries. Copyright © 2013 Elsevier Inc. All rights reserved.
Chapman, AWP; Krikler, S; Krkovic, M
Introduction There has been recent interest in the use of negative pressure wound therapy (NWPT) as an adjunct to parenteral antibiotics in the treatment of infection in orthopaedic patients with metalwork in situ. To address some of the limitations of standard NPWT in this situation, the senior author has developed a modified method of treatment for infected metalwork (excluding arthroplasty) in orthopaedic patients that includes irrigation and skin closure over the standard NPWT dressing. Methods This retrospective study examined the outcome of a case series of 16 trauma and orthopaedic patients with deep infection involving metalwork in whom this modified form of NPWT was used. In conjunction with standard parenteral antibiotic therapy and a multidisciplinary approach, this modified technique included serial debridements in theatre, irrigation and negative pressure dressings over a white polyvinyl alcohol foam (KCI, Kidlington, UK) as well as closure of the skin over the foam. Results Among the 16 patients, there was a variety of upper and lower limb as well as spinal trauma and elective cases. In all 16 patients, there was successful resolution of the infection with no early or unplanned removal of any metalwork required. Conclusions Patients with infected metalwork are a heterogeneous group, and often suffer high morbidity and mortality. The modified NPWT technique shows potential as an adjunct in the treatment of complex orthopaedic patients with infected metalwork. PMID:23484994
Johnson, P C; Satterwhite, T K; Monheit, J E; Parks, D
Primary cutaneous mucormycosis in trauma patients has been rarely reported. We describe three cases occurring in noncompromised hosts and review the literature. Prompt diagnosis and aggressive treatment with vigorous local care and appropriate antibiotics are recommended.
... Antitrust Division United States v. Idaho Orthopaedic Society, Timothy Doerr, Jeffrey Hessing, Idaho Sports.... Idaho Orthopaedic Society, Timothy Doerr, Jeffrey Hessing, Idaho Sports Medicine Institute, John Kloss..., Plaintiffs, vs. Idaho Orthopaedic Society, Timothy Doerr, Jeffrey Hessing, Idaho Sports Medicine Institute...
Abbas, Tariq O; Hayati, Ahmed; Ali, Mansour
Although laparoscopy is rapidly becoming the abdominal surgical modality of choice in adults, there are obstacles to its use in children. We analyzed our experience with pediatric laparoscopic surgery over the past 5 years, with particular emphasis on emergency procedures. We retrospectively evaluated the records of patients aged <14 years who had undergone laparoscopic procedures for non-trauma emergency conditions at our institution from January 2006 to December 2010. The clinical parameters evaluated included operation time, total length of hospital stay, and postoperative complications.During the 5-year study period, 482 laparoscopic procedures were performed on patients aged <14 years, comprising 300 emergency and 182 elective operations. The majority of procedures were laparoscopic appendectomies, with most of the others being resections of ovarian cysts or Meckel's diverticulae, or adhesiolyses. We observed an improvement in outcomes over the 5-year period, as shown by shorter operation times and shorter postoperative hospital stays. The numbers of laparoscopic procedures performed increased over time. Pediatric laparoscopic surgery for emergency conditions provides excellent results, including better exposure and cosmetic outcomes than laparotomy. At our institution, the numbers and types of laparoscopic procedures performed have increased over time, and the outcomes of laparoscopic procedures have improved.
Background Although laparoscopy is rapidly becoming the abdominal surgical modality of choice in adults, there are obstacles to its use in children. We analyzed our experience with pediatric laparoscopic surgery over the past 5 years, with particular emphasis on emergency procedures. Findings We retrospectively evaluated the records of patients aged <14 years who had undergone laparoscopic procedures for non-trauma emergency conditions at our institution from January 2006 to December 2010. The clinical parameters evaluated included operation time, total length of hospital stay, and postoperative complications. During the 5-year study period, 482 laparoscopic procedures were performed on patients aged <14 years, comprising 300 emergency and 182 elective operations. The majority of procedures were laparoscopic appendectomies, with most of the others being resections of ovarian cysts or Meckel’s diverticulae, or adhesiolyses. We observed an improvement in outcomes over the 5-year period, as shown by shorter operation times and shorter postoperative hospital stays. The numbers of laparoscopic procedures performed increased over time. Conclusions Pediatric laparoscopic surgery for emergency conditions provides excellent results, including better exposure and cosmetic outcomes than laparotomy. At our institution, the numbers and types of laparoscopic procedures performed have increased over time, and the outcomes of laparoscopic procedures have improved. PMID:23035990
Staruch, RMT; Griffin, MF; Butler, PEM
Background: Orthopaedic implants such as the total hip or total knee replacement are examples of surgical interventions with postoperative success rates of over 90% at 10 years. Implant failure is associated with wear particles and pain that requires surgical revision. Improving the implant - bone surface interface is a key area for biomaterial research for future clinical applications. Current implants utilise mechanical, chemical or physical methods for surface modification. Methods: A review of all literature concerning the nanoscale surface modification of orthopaedic implant technology was conducted. Results: The techniques and fabrication methods of nanoscale surface modifications are discussed in detail, including benefits and potential pitfalls. Future directions for nanoscale surface technology are explored. Conclusion: Future understanding of the role of mechanical cues and protein adsorption will enable greater flexibility in surface control. The aim of this review is to investigate and summarise the current concepts and future directions for controlling the implant nanosurface to improve interactions. PMID:28217214
Johnson, Amanda L; Sharma, Jyoti; Chinchilli, Vernon M; Emery, Sanford E; McCollister Evarts, C; Floyd, Mark W; Kaeding, Christopher C; Lavelle, William F; Marsh, J Lawrence; Pellegrini, Vincent D; Van Heest, Ann E; Black, Kevin P
The primary influence on medical students' career choice is their third-year clerkship. However, orthopaedics is not a required rotation in the curriculum of most medical schools. Our goals were to identify factors that motivate students to choose an orthopaedic career and to compare these with the factors that influence students to choose nonorthopaedic disciplines. Fourth-year medical students and orthopaedic residents at the postgraduate year (PGY)-1 level at eight orthopaedic training programs in the United States were surveyed to determine the reasons that they chose orthopaedics instead of other medical or surgical fields. Of the 622 individuals who responded to our survey, 125 were entering orthopaedics and 497 were not. Although career choice in both groups was most heavily influenced by third and fourth-year clinical rotations and faculty contacts, orthopaedics-bound respondents were more likely than non-orthopaedics-bound respondents to be strongly influenced by experiences and people prior to medical school. Orthopaedics-bound respondents were less likely to report a faculty member as the most important person influencing career choice. Fifty-one percent (sixty-three) of 124 students who selected orthopaedics had already decided to pursue this field prior to their third-year rotation. Patient care was chosen by 71% (347) of 490 non-orthopaedics-bound respondents and 75% (ninety-four) of 125 orthopaedics-bound respondents as the most important factor for pursuing a particular field. Income was not selected as the deciding factor by respondents in either group. Although faculty contacts and third-year clinical rotations played an important role in student selection of specialty training, they were less influential for those choosing an orthopaedic career than for those choosing other disciplines. Many students choosing orthopaedics made this decision prior to medical school. We believe that increased exposure to positive clinical role models and
Hariri, Sanaz; York, Sally C; O'Connor, Mary I; Parsley, Brian S; McCarthy, Joseph C
An orthopaedic workforce shortage has been projected. The purpose of this study is to analyze the supply side of this shortage by ascertaining the career plans of current orthopaedic residents, comparing these plans with the career patterns of practicing orthopaedists, and identifying career-plan differences according to sex. An online, self-administered survey was e-mailed to U.S. orthopaedic residents in postgraduate year three or higher, querying them about their fellowship specialty choice and their career plans. A total of 498 residents completed the online survey; 430 respondents (86%) were male, sixty-three (13%) were female, and five (1%) did not provide information regarding sex. Ninety-one percent of the residents were planning to enroll in a fellowship, with some respondents indicating more than one subspecialty choice: 28% intended to choose sports; 21%, arthroplasty; 14%, hand surgery, 12%, trauma; 8%, pediatrics; 8%, shoulder and elbow surgery; 8%, spine surgery; 6%, foot and ankle surgery; and 2%, oncology. With regard to the top career priorities of residents in selecting a fellowship specialty, 40% indicated intellectual priorities; 36%, educational; 21%, lifestyle; and 4%, economic. Significantly more women than men were planning on pursuing a pediatric fellowship (24% versus 6%, respectively, p < 0.05) and significantly fewer were planning on pursuing a sports fellowship (11% versus 31%, respectively, p < 0.05). Significantly more women than men planned on a subspecialty-only practice (62% versus 34%, respectively, p < 0.05). The projected retirement age of sixty-four years for current residents is roughly equal to that of the previous generation. There was no difference between men and women with regard to leadership and research aspirations, projected retirement age, and projected workdays per week. However, significantly more women than men (65% versus 47%, respectively) planned on reducing their work hours or changing to part-time status at
Summerton, Duncan J; Kitrey, Noam D; Lumen, Nicolaas; Serafetinidis, Efraim; Djakovic, Nenad
The European Association of Urology (EAU) Trauma Guidelines Panel presents an updated iatrogenic trauma section of their guidelines. Iatrogenic injuries are known complications of surgery to the urinary tract. Timely and adequate intervention is key to their management. To assess the optimal evaluation and management of iatrogenic injuries and present an update of the iatrogenic section of the EAU Trauma Guidelines. A systematic search of the literature was conducted, consulting Medline and the Cochrane Register of Systematic reviews. No time limitations were applied, although the focus was on more recent publications. The expert panel developed statements and recommendations. Statements were rated according to their level of evidence, and recommendations received a grade following a rating system modified from the Oxford Centre for Evidence-based Medicine. Currently, only limited high-powered studies are available addressing iatrogenic injuries. Because the reporting of complications or sequelae of interventions is now increasingly becoming a standard requirement, this situation will likely change in the future. This section of the trauma guidelines presents an updated overview of the treatment of iatrogenic trauma that will be incorporated in the trauma guidelines available at the EAU Web site (http://www. uroweb.org/guidelines/online-guidelines/). Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Schonfeld, Deborah; Lee, Lois K
This review will examine the current evidence regarding pediatric blunt abdominal trauma and the physical exam findings, laboratory values, and radiographic imaging associated with the diagnosis of intra-abdominal injuries (IAI), as well as review the current literature on pediatric hollow viscus injuries and emergency department disposition after diagnosis. The importance of the seat belt sign on physical examination and screening laboratory data remains controversial, although screening hepatic enzymes are recommended in the evaluation of nonaccidental trauma to identify occult abdominal organ injuries. Focused Assessment with Sonography for Trauma (FAST) has modest sensitivity for hemoperitoneum and IAI in the pediatric trauma patient. Patients with concern for undiagnosed IAI, including bowel injury, may be considered for hospital admission and serial abdominal exams without an increased risk of complications, if an exploratory laparotomy is not performed emergently. Although the FAST exam is not recommended as the sole screening tool to rule out IAI in hemodynamically stable trauma patients, it may be used in conjunction with the physical exam and laboratory findings to identify children at risk for IAI. Children with a normal physical exam and normal abdominal CT may not require routine hospitalization after blunt abdominal trauma.
CATLEDGE, S.A.; THOMAS, V.; VOHRA, Y.K.
With increasing numbers of orthopaedic devices being implanted, greater emphasis is being placed on ceramic coating technology to reduce friction and wear in mating total joint replacement components, in order to improve implant function and increase device lifespan. In this chapter, we consider ultra-hard carbon coatings, with emphasis on nanostructured diamond, as alternative bearing surfaces for metallic components. Such coatings have great potential for use in biomedical implants as a result of their extreme hardness, wear resistance, low friction and biocompatibility. These ultra-hard carbon coatings can be deposited by several techniques resulting in a wide variety of structures and properties. PMID:25285213
Catledge, S A; Thomas, V; Vohra, Y K
With increasing numbers of orthopaedic devices being implanted, greater emphasis is being placed on ceramic coating technology to reduce friction and wear in mating total joint replacement components, in order to improve implant function and increase device lifespan. In this chapter, we consider ultra-hard carbon coatings, with emphasis on nanostructured diamond, as alternative bearing surfaces for metallic components. Such coatings have great potential for use in biomedical implants as a result of their extreme hardness, wear resistance, low friction and biocompatibility. These ultra-hard carbon coatings can be deposited by several techniques resulting in a wide variety of structures and properties.
Volgas, David A; Stannard, James P; Alonso, Jorge E
The purpose of this review is to examine current orthopaedic treatment of gunshot wounds. Surgeons are increasingly confronted by gunshot wounds that occur in both military and civilian settings. Much of the published work has been from military settings. In the United States, low-energy gunshot wounds are very common, and their incidence is increasing elsewhere in the world. Current treatment and its rationale is reviewed and a systematic approach to the assessment and treatment of these injuries is offered, taking into account the entirety of the injury, rather than simply the velocity of the missile.
Cerciello, Simone; Rossi, Silvio; Visonà, Enrico; Corona, Katia; Oliva, Francesco
Summary Background Vibration therapy (VT) has been proposed as an option to improve physical performance and reduce the negative effects of ageing on bone, muscles and tendons. Several discrepancies exist on the type of applications, frequency and magnitude. These differences reflex on the contradictory clinical results in literature. Aim of the present study is to carry on an exhaustive review to focus on technical options on the market, clinical applications in orthopaedic practice and expected outcomes. Methods a literature review using the key words “vibration therapy” and “whole-body vibration” and “orthopaedics” was performed. After checking the available abstracts 71 full text articles were evaluated. Results fifty-one articles focused on the effects of VT on muscles and tendons reporting ways of action and clinical outcomes. In a similar way 20 studies focused on the influence of VT on bone tissue with regard on ways of action and clinical trials. Conclusions VT provides anabolic mechanical signals to bone and musculo-tendinous system. The best effects seem to be achieved with devices that deliver low-intensity stimuli at high frequencies providing linear horizontal displacement. PMID:27331044
van Vugt, A B
Introduction of the principles of advanced trauma life support (ATLS) in the management of accident victims has been in progress in the Netherlands since 1995. The main ATLS principles are that the aid giver treats the most dangerous disorder first and does no further damage. After assessment and, if necessary, treatment of the airways, the respiration, the circulation and any craniocerebral injury, an exploratory examination is carried out. Physicians receive theoretical and practical instructions in this form of management during an intensive two-day course, counselled by a coordinating organization in the USA. Most of those attending are interns in general surgery, traumatology and orthopaedics, gatekeeper doctors of emergency rooms and army medical officers. The standardized way of thinking improves the communication and understanding between the various disciplines involved in trauma care, in part because there exist comparable programmes for ambulance care and emergency care. Other measures improving the quality of trauma care are regionalization of the trauma care, medical helicopter teams and evaluation of the effects of ATLS as an operating procedure.
Wardlaw, F B; McGuire, F A; Overby, Z
Therapeutic recreation is a viable rehabilitation treatment for orthopaedic disabilities. Interdisciplinary treatment teams should consider therapeutic recreation interventions using the Health Prevention/Health Promotion Model in management of orthopaedic disabilities to enhance the client's present level of functioning to optimal health.
Yagmurlu, Bilge; Yavuz, H. Melis
The aim of the study was to investigate social competence in children with orthopaedic disability and its concurrent relations to child's temperament, health condition, and maternal warmth. Participants were 68 Turkish children (mean = 5.94 years) with chronic orthopaedic disability and their mothers coming from disadvantaged backgrounds. Mother…
Yagmurlu, Bilge; Yavuz, H. Melis
The aim of the study was to investigate social competence in children with orthopaedic disability and its concurrent relations to child's temperament, health condition, and maternal warmth. Participants were 68 Turkish children (mean = 5.94 years) with chronic orthopaedic disability and their mothers coming from disadvantaged backgrounds. Mother…
Daniels, Alan H; Grabel, Zachary; DiGiovanni, Christopher W
Orthopaedic surgery training in the United States consists of a five-year-minimum orthopaedic surgery residency program, followed by optional subspecialty fellowship training. There is an increasing trend for trainees to complete at least one fellowship program following residency training, with approximately 90% of current trainees planning to complete a fellowship. The purpose of this investigation was to assess the overall variability of orthopaedic subspecialty fellowships in terms of characteristics, match process, and the tendency to be accredited by the Accreditation Council for Graduate Medical Education. Nine orthopaedic surgery subspecialties were assessed for their fellowship match program, their number of fellowship programs and positions in the match, and the number of programs and positions accredited by the Accreditation Council for Graduate Medical Education. Programs with a Subspecialty Certificate offered by the American Board of Orthopaedic Surgery were compared with programs without a Subspecialty Certificate. Comparative statistics utilizing an unpaired t test with a statistical cutoff of p < 0.05 were performed. Three separate matching programs are used by the nine subspecialties. Hand surgery utilizes the National Residents Matching Program, shoulder and elbow surgery utilizes the American Shoulder and Elbow Surgeons Fellowship Match, and the other seven subspecialties utilize the San Francisco Matching Program. In total, 478 fellowship programs were identified, representing 897 fellowship positions. The highest percentage of fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education was in orthopaedic sports medicine (93.1%), compared with the lowest percentage in foot and ankle orthopaedics (16.3%). A significantly higher percentage (p < 0.05) of fellowship programs accredited by the Accreditation Council for Graduate Medical Education were found for subspecialties with American Board of Orthopaedic
Campbell, B; Heal, J; Evans, S; Marriott, S
Advanced trauma life support (ATLS) has become a desirable or even essential part of training for many surgeons and anaesthetists, but aspects of the ATLS course have attracted criticism. In the absence of published data on the views of trainees, this study sought their opinions in a structured questionnaire, which was completed by trainees in accident and emergency (A & E) (26), anaesthetic (82), general surgical (26), orthopaedic (42) and other (5) posts in different hospitals (response rate 66%). Of the trainees, 78% had done an ATLS course and, of these, 83% considered ATLS a 'major advantage' or 'essential' for practising their proposed specialty--100% for A & E, 94% for orthopaedics, 92% for general surgery, and 75% for anaesthetics. ATLS was considered a major curriculum vitae (CV) advantage by 94%, 85%, 50%, and 45%, respectively. Over 90% had positive attitudes towards ATLS, and 74% selected 'genuine improvement of management of trauma patients' as the most important reason for doing the course: 93% thought ATLS saved lives. Of the respondents, 83% thought that all existing consultants dealing with trauma patients should have done the course, and 41% thought it offered major advantages to doctors not involved in trauma. Funding problems for ATLS courses had been experienced by 14% trainees. This survey has shown that most trainees view ATLS positively. They believe that it provides genuine practical benefit for patients, and very few regard ATLS primarily as a career advantage or mandate.
Campbell, B.; Heal, J.; Evans, S.; Marriott, S.
Advanced trauma life support (ATLS) has become a desirable or even essential part of training for many surgeons and anaesthetists, but aspects of the ATLS course have attracted criticism. In the absence of published data on the views of trainees, this study sought their opinions in a structured questionnaire, which was completed by trainees in accident and emergency (A & E) (26), anaesthetic (82), general surgical (26), orthopaedic (42) and other (5) posts in different hospitals (response rate 66%). Of the trainees, 78% had done an ATLS course and, of these, 83% considered ATLS a 'major advantage' or 'essential' for practising their proposed specialty--100% for A & E, 94% for orthopaedics, 92% for general surgery, and 75% for anaesthetics. ATLS was considered a major curriculum vitae (CV) advantage by 94%, 85%, 50%, and 45%, respectively. Over 90% had positive attitudes towards ATLS, and 74% selected 'genuine improvement of management of trauma patients' as the most important reason for doing the course: 93% thought ATLS saved lives. Of the respondents, 83% thought that all existing consultants dealing with trauma patients should have done the course, and 41% thought it offered major advantages to doctors not involved in trauma. Funding problems for ATLS courses had been experienced by 14% trainees. This survey has shown that most trainees view ATLS positively. They believe that it provides genuine practical benefit for patients, and very few regard ATLS primarily as a career advantage or mandate. PMID:10932661
Oestern, Hans-Joerg; Garg, Bhavuk; Kotwal, Prakash
Road traffic accidents are among the leading causes of death worldwide in individuals younger than 45 years. In both India and Germany, there has been an increase in registered motor vehicles over the last decades. However, while the number of traffic accident victims steadily dropped in Germany, there has been a sustained increase in India. We analyze this considering the sustained differences in rescue and trauma system status. We compared India and Germany in terms of (1) vehicular infrastructure and causes of road traffic accident-related trauma, (2) burden of trauma, and (3) current trauma care and prevention, and (4) based on these observations, we suggested how India and other countries can enhance trauma care and prevention. Data for Germany were obtained from federal statistical databases, German Automobile Club, and German Trauma Registry. Data from India were available from the Ministry of Road Transport and Highways. We also performed a standardized literature search of PubMed for India and Germany using the following key words: "road traffic accidents", "prevention", "prehospital trauma care", "trauma system", "trauma registry", "trauma centers", and "development of vehicles." The total number of registered motor vehicles increased 473-fold in India and 100-fold in Germany from 1951 to 2011. The number of road traffic deaths increased in both countries until 1970, but thereafter decreased in Germany (3606 in 2012) while continuing to increase in India (142,485 in 2011). The differences between Germany and India relate to the relative sizes and populations of the countries (1:9 and 1:15, respectively), and differences in prevention and prehospital care (nationwide versus big cities) and hospital trauma systems (nationwide versus exceptional). Improvement requires attention to three major issues: (1) prevention through infrastructure, traffic laws, mandatory licensing; (2) establishment of a prehospital care system; and (3) establishment of regional
Sales, Jessica M; Swartzendruber, Andrea; Phillips, Ashley L
The high prevalence of trauma and its negative impact on health and health-promoting behaviors underscore the need for multi-level interventions to address trauma and its associated sequelae to improve physical and mental well-being in both HIV-infected and HIV-uninfected populations. Growing global awareness of the intersection of trauma and HIV has resulted in development and testing of interventions to address trauma in the context of HIV treatment and HIV prevention in the USA and globally. Despite increasing recognition of the widespread nature of trauma and the importance of trauma to HIV transmission around the globe, several gaps remain. Through a survey of the literature, we identified eight studies (published in the past 5 years) describing interventions to address the effects of trauma on HIV-related outcomes. In particular, this study focused on the levels of intervention, populations the interventions were designed to benefit, and types of trauma addressed in the interventions in the context of both HIV prevention and treatment. Remarkably absent from the HIV prevention, interventions reviewed were interventions designed to address violence experienced by men or transgender individuals, in the USA or globally. Given the pervasive nature of trauma experienced generally, but especially among individuals at heightened risk for HIV, future HIV prevention interventions universally should consider becoming trauma-informed. Widespread acknowledgement of the pervasive impact of gender-based violence on HIV outcomes among women has led to multiple calls for trauma-informed care (TIC) approaches to improve the effectiveness of HIV services for HIV-infected women. TIC approaches may be relevant for and should also be tested among men and all groups with high co-occurring epidemics of HIV and trauma (e.g., men who have sex with men (MSM), transgendered populations, injection drug users, sex workers), regardless of type of trauma experience.
Atesok, Kivanc; Doral, M Nedim; Karlsson, Jon; Egol, Kenneth A; Jazrawi, Laith M; Coelho, Paulo G; Martinez, Amaury; Matsumoto, Tomoyuki; Owens, Brett D; Ochi, Mitsuo; Hurwitz, Shepard R; Atala, Anthony; Fu, Freddie H; Lu, Helen H; Rodeo, Scott A
The purpose of this study was to summarize the recent developments in the field of tissue engineering as they relate to multilayer scaffold designs in musculoskeletal regeneration. Clinical and basic research studies that highlight the current knowledge and potential future applications of the multilayer scaffolds in orthopaedic tissue engineering were evaluated and the best evidence collected. Studies were divided into three main categories based on tissue types and interfaces for which multilayer scaffolds were used to regenerate: bone, osteochondral junction and tendon-to-bone interfaces. In vitro and in vivo studies indicate that the use of stratified scaffolds composed of multiple layers with distinct compositions for regeneration of distinct tissue types within the same scaffold and anatomic location is feasible. This emerging tissue engineering approach has potential applications in regeneration of bone defects, osteochondral lesions and tendon-to-bone interfaces with successful basic research findings that encourage clinical applications. Present data supporting the advantages of the use of multilayer scaffolds as an emerging strategy in musculoskeletal tissue engineering are promising, however, still limited. Positive impacts of the use of next generation scaffolds in orthopaedic tissue engineering can be expected in terms of decreasing the invasiveness of current grafting techniques used for reconstruction of bone and osteochondral defects, and tendon-to-bone interfaces in near future.
Zartman, Kevin C; Berlet, Gregory C; Hyer, Christopher F; Woodard, Joseph R
The use of metals as implant materials has become common practice in the field of orthopaedics. A wide variety of conditions are treated with metallic implants, and designers have used an assortment of materials to meet the unique mechanical demands of each application. The majority of implants used today, whether pins, plates, screws, or total joints, are made of cobalt-chrome alloy, stainless steel, or titanium. Common metallurgic wisdom cautions against bonding dissimilar metals in a biologically active environment. Surgeons have therefore shied away from combining dissimilar metal implants because of the fear of inciting corrosion that could potentially compromise the implants and lead to aseptic loosening, implant failure, or adverse biological reaction in host tissue. As surgical reconstruction and arthroplasty options expand with the advent of newer implants and expanded operative techniques, the orthopaedic surgeon will increasingly be faced with weighing the risks and benefits of combining implants made of dissimilar metals in a patient. Here, the authors examine the origins of the concern over using mixed metals, discuss mechanisms of corrosion as they relate to surgical implants, and review both in vitro and in vivo studies concerning the most common combinations of dissimilar metals in order to guide the surgeon in choosing implants.
Poenaru, Dan V
The historical and geographical territory of Banat is part of present-day Romania. Timisoara's history, the capital city of Banat region, dates back to the second century B.C. Medical life in Banat was re-organised after the promulgation of the Aulic Laws in the eighteenth century. Thorough research was undertaken through historic manuscripts, old newspapers, biographies and other papers about the history of Romanian medicine. The eighteenth century witnessed the building of three hospitals in Timisoara. In that period, Banat region benefited from the expertise and professionalism of doctors who graduated and were trained mainly in Central and Western European universities. By the beginning of the twentieth century, many medical clinics or sanatoriums specialising in orthopaedics and traumatology were offering their services to the population. Banat region had many good orthopaedists, and one of them was Prof. Dr. Doc. Berceanu, who graduated from the University of Medicine Bucharest and further specialised in Paris, France. He is the founder of the Orthopaedics and Traumatology Clinic in Timisoara.
Harms, Louise; Talbot, Michelle
For many survivors of serious road trauma, the physical and psychological consequences are complex and lifelong. The longer-term psychosocial recovery experience for survivors, however, is rarely documented in the social work literature. This article reports on findings from a study of road trauma recovery experiences. The findings are presented…
Harms, Louise; Talbot, Michelle
For many survivors of serious road trauma, the physical and psychological consequences are complex and lifelong. The longer-term psychosocial recovery experience for survivors, however, is rarely documented in the social work literature. This article reports on findings from a study of road trauma recovery experiences. The findings are presented…
Elliott, Iain S; Sonshine, Daniel B; Akhavan, Sina; Slade Shantz, Angelique; Caldwell, Amber; Slade Shantz, Jesse; Gosselin, Richard A; Coughlin, R Richard
research process (26%) and institutional barriers (28%). Drivers of research discussed at least once were proportionally similar across the three domains. Some themes such as research ethics boards, technology, and literature access occurred with similar frequency as barriers to and drivers of orthopaedic surgery research. The barriers we identified most often among East African academic orthopaedic faculty members focused on resources to accomplish research, followed by institutional barriers, and method or process barriers. Drivers to be fostered included a desire to effect change, collaboration with colleagues, and mentorship opportunities. The identified barriers and drivers of research in East Africa provide a targeted framework for interventions and collaborations with surgeons and organizations from high-resource settings looking to be involved in global health.
Kumar, Aj Shyam; Oakley, J; Wong, Shaun K S; Philips, Steve J
Induction programme for trainee doctors in the UK generally do not focus on the surgical aspects of their jobs. In this context we decided to conduct a telephonic survey among the hospitals belonging to three orthopaedic training regions in the UK from the point of view of the diversity of instrumentations and implants used for index procedures. We chose four index trauma & orthopaedic procedures (Total hip replacement, total knee replacement, intramedullary nailing and external fixator systems for long bone fractures). A telephonic survey was done in six NHS trust hospitals which were part of an orthopaedic training rotation (2 from England, 2 from Wales and 2 from Scotland). In total there were 39 different instrumentation systems for these 4 index procedures in the 6 trusts (see table 1). These comprise 12 Total hip replacement (THR) systems, 14 total knee replacement (TKR) systems, 9 intra-medullary nailing systems, and 4 external fixator systems. The number of different systems for each trust ranged from 7 to 19. There is a vast array of implants and instrumentation systems in each trust, as highlighted by our survey. The surgical tools are not the same in each hospitals. This situation is more complicated when trainees move to new hospitals as part of training rotations. In view of this we feel that more focused theatre based induction programmes for higher surgical trainees is advocated in each hospital trust so trainees can familiarise themselves with the tools available to them. This could include discussion with the consultants and senior theatre staff along with representatives from the companies supplying the implants and instrumentation systems.
... War Specific to Women Types of Trauma War Terrorism Violence and Abuse Disasters Is it PTSD? Treatment ... Overview Types of Trauma Trauma Basics Disaster and Terrorism Military Trauma Violence & other Trauma Assessment Assessment Overview ...
Torres-Torres, M; Mingo-Robinet, J; Moreno Barrero, M; Rivas Laso, J Á; Burón Álvarez, I; González Salvador, M
To analyse the exposure of two Orthopaedic Surgeons to ionizing radiations in their daily work, and to review the main national and international recommendations on this subject. A retrospective study was conducted on the surgical treatments that use fluoroscopy performed by two Orthopaedic Surgeons during a one year period. An evaluation was made of the radiation received, based on measurements of the processes published in the bibliography section. A literature review of international recommendations and regulations is also presented. The radiation received by the two Orthopaedic Surgeons during one year did not exceed the limits of present-day legislation or the new European and international recommendations. The exposure was asymmetrical, with the hands being the most radiated part. The new recommendations reduce the permitted level of radiation on eyes. The evaluation of the radiation received demonstrates the need for radiation protection, paying particular attention to the hands and eyes. Good knowledge of operating a fluoroscope and radiation safety measures are also essential. Copyright © 2014 SECOT. Published by Elsevier Espana. All rights reserved.
Matsushita, Masaki; Kitoh, Hiroshi; Itomi, Kazuya; Kitakoji, Takahiko; Iwata, Koji; Mishima, Kenichi; Ishiguro, Naoki; Hattori, Tadashi
Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy characterized by symmetric limb weakness. Children with GBS sometimes consult the orthopaedists because of limb pain and gait disturbance. The orthopaedists, however, are unfamiliar with GBS, since it has rarely been delineated in detail in the orthopaedic literature. In the present study, we specifically describe orthopaedic manifestations and diagnostic clues in pediatric GBS. We reviewed seven patients with pediatric GBS in regard to age, gender, clinical symptoms, department at the first medical consultation, initial diagnosis, physical and laboratory findings, medical interventions, and the latest clinical outcome. There were five boys and two girls, with a mean age at presentation of 7.2 years. Gait disturbance associated with lower limb pain and weakness was the most frequent early clinical symptom. Among the five patients who presented initially at the orthopaedic department, three were misdiagnosed. Loss of deep tendon reflexes was seen in all patients. Anti-ganglioside antibodies were positive in three and protein levels of cerebrospinal fluid were elevated in five patients. Six patients recovered completely after intravenous immunoglobulin (IVIG) treatment, while one patient who had not undergone IVIG treatment showed minor residual disability. Acute symmetrical limb pain and gait disturbance associated with loss of tendon reflexes were important clinical manifestations of pediatric GBS. Early diagnosis is essential to prevent delayed recovery, long-term weakness, and permanent functional disabilities.
Farmer, Ryan P; Herbert, Benoit; Cuellar, Derly O; Hao, Jiandong; Stahel, Philip F; Yasui, Robin; Hak, David J; Mauffrey, Cyril
Osteoporosis has been recognised as a public health concern for at least three decades but it has been relatively recent that the push has been for orthopaedic surgeons to take a more active role in the diagnosis and treatment of patients with decreased bone mineral density (BMD). Most often these patients are encountered after they have suffered a fracture making secondary prevention the area where orthopaedists may exert the greatest influence on patient care. The purpose of this article is to provide a succinct framework for the diagnosis and treatment of patients with decreased BMD. Patients are deemed to have decreased BMD if they have suffered a fragility fracture, a fracture caused by a low-energy traumatic event. These patients are often encountered in the emergency department and admitted for further treatment of their fractures or recommended for follow-up in the clinic. Regardless of treatment course these are opportunities for the orthopaedic surgeon to intervene in the osteoporotic disease process and positively affect a patient's bone health. This article compiles the available literature on osteoporosis and presents it succinctly with the incorporation of both a diagnosis algorithm and treatment profile table. With the use of these two tools, orthopaedic surgeons everywhere should be able to take a more active role in their patients' bone health.
Vojtassák, J; Sefránková, A; Maresch, P; Rehák, L
At the First Orthopaedic Clinic in Bratislava during the last two years 748 children were hospitalized. Of these 405 had surgical operations: 260 operations of bones, 61 operations of joints and 84 operations of soft parts. Patiens with osteomyelitis and pyarthrosis were hospitalized in 0,5 %, with reactive arthritis in 0,6 % (not associated with the surgical operation made in the authors' department). For prophylactic and therapeutic administration of antibiotics Ampicillin was administered in 266%, Oxacillin in 15,8 %, Cephalosporins in 12,8 %. Prophylactic administration of antibiotics, incl. the first dose before surgery, accounted for 626%. After this antibiotic prophylaxis the inci dence of secondary chronic osteomyelitis was 0,24 %. Surface infections of the wound were re corded in 3,4 % and deep infections in 1,2 %. Non-orthopaedic infections (mainly upper respira tory pathway infections) during the postoperative period occurred in 7,1 %, they varied, however, de pending on the epidemiological situation. Based on their own observations and data in the literature the authors recommend antibiotic prophylaxis in children for 24-48 hours in the following order: Cephalosporins, Oxacillin, Ampicillin. When changing from prophylactic to therapeutic antibiotic administration it is necessary to take into account the clinical picture and state of the wound. Febrility, red cell sedimentation rate, Le do not always correlate with the infection of the wound. In children during the postoperative period also frequent non-orthopaedic infections must be taken into account. Key words: osteoarticular infection, incidence, antibiotic prophylaxis.
Sargeant, Timothy David
For bone regeneration, there is need for biodegradable, synthetic scaffolds that direct the formation of de novo mineralized tissue. Orthopaedic implants additionally require mechanical function. The work described herein attempts to address both of these needs. The general strategy involves integrating molecularly designed tissue engineering scaffolds with porous metallic foams to create hybrid materials to direct cellular behavior. Peptide amphiphiles (PAs) that self-assemble into nanofibers were designed to template hydroxyapatite mineral under biological conditions. The molecular design incorporated either serine (S) or phosphoserine S(P) and was mixed with RGDS-bearing PA to evaluate of the key parameters for mineral formation. This led to the discovery of nanoscale hydroxyapatite spheres templated on both S- and S(P)-bearing PA nanofibers. Stem cells were encapsulated in these gels and RT-PCR showed osteoblastic differentiation in all samples. Osteoblast maturation was increased in S-bearing PA compared to S(P)-bearing PA, although the reason is not yet understood. A method to create robust PA nanofiber coatings on NiTi was developed by optimizing the NiTi oxide surface chemistry, optimizing silane vapor deposition, and covalently attaching the PAs to the silanized substrate. The surfaces were characterized by XPS, SIMS, AFM, and fluorimetry. In vitro experiments demonstrated the importance of covalent attachment for cellular adhesion and proved the materials were not cytotoxic. Orthopaedic hybrid materials were created by triggering PA self-assembly within the interconnected pores of Ti foams developed by the Dunand research group. In vitro experiments demonstrate that pre-osteoblasts adhere to, proliferate on, and migrate into PA-Ti hybrids made with S(P)- and RGDS-bearing PA mixtures. The cells differentiate into mature osteoblasts and remain viable up to 28 days. In vivo studies using a rat model demonstrate osteointegration and boney ingrowth into bare
Sagi, H C; DiPasquale, Thomas; Sanders, Roy; Herscovici, Dolfi
To determine if the exhaust from surgical compressed-air power tools contains bacteria and if the exhaust leads to contamination of sterile surfaces. Bacteriologic study of orthopaedic power tools. Level I trauma center operative theater. None. Part I. Exhaust from two sterile compact air drills was sampled directly at the exhaust port. Part II. Exhaust from the drills was directed at sterile agar plates from varying distances. The agar plates represented sterile surfaces within the operative field. Part III. Control cultures. A battery-powered drill was operated over open agar plates in similar fashion as the compressed-air drills. Agar plates left open in the operative theater served as controls to rule out atmospheric contamination. Random cultures were taken from agar plates, gloves, drills, and hoses. Incidence of positive cultures. In Part I, all filters from both compressed-air drill exhausts were culture negative ( = 0.008). In Part II, the incidence of positive cultures for air drills number one and number two was 73% and 82%, respectively. The most commonly encountered organisms were, coagulase-negative Staphylococcus, and Micrococcus species. All control cultures from agar plates, battery-powered drill, gloves, and hoses were negative ( < 0.01). Exhaust from compressed-air power tools in orthopaedic surgery may contribute to the dissemination of bacteria onto the surgical field. We do not recommend the use of compressed-air power tools that do not have a contained exhaust.
Dancer, Stephanie J; Christison, Fraser; Eslami, Attaolah; Gregori, Alberto; Miller, Roslyn; Perisamy, Kumar; Robertson, Chris; Graves, Nick
Background With recent focus on methicillin-resistant Staphylococcus aureus (MRSA) screening, methicillin-susceptible S. aureus (MSSA) has been overlooked. MSSA infections are costly and debilitating in orthopaedic surgery. Methods We broadened MRSA screening to include MSSA for elective orthopaedic patients. Preoperative decolonisation was offered if appropriate. Elective and trauma patients were audited for staphylococcal infection during 2 6-month periods (A: January to June 2013 MRSA screening; B: January to June 2014 MRSA and MSSA screening). Trauma patients are not screened presurgery and provided a control. MSSA screening costs of a modelled cohort of 500 elective patients were offset by changes in number and costs of MSSA infections to demonstrate the change in total health service costs. Findings Trauma patients showed similar infection rates during both periods (p=1). In period A, 4 (1.72%) and 15 (6.47%) of 232 elective patients suffered superficial and deep MSSA infections, respectively, with 6 superficial (2%) and 1 deep (0.3%) infection among 307 elective patients during period B. For any MSSA infection, risk ratios were 0.95 (95% CI 0.41 to 2.23) for trauma and 0.28 (95% CI 0.12 to 0.65) for elective patients (period B vs period A). For deep MSSA infections, risk ratios were 0.58 (95% CI 0.20 to 1.67) for trauma and 0.05 (95% CI 0.01 to 0.36) for elective patients (p=0.011). There were 29.12 fewer deep infections in the modelled cohort of 500 patients, with a cost reduction of £831 678 for 500 patients screened. Conclusions MSSA screening for elective orthopaedic patients may reduce the risk of deep postoperative MSSA infection with associated cost-benefits. PMID:27601492
Hiquet, Jean; Gromb-Monnoyeur, Sophie
The use of Flash-Ball® as a non-lethal weapon by several special units within the police and police forces started in France in 1995. Little literature is available concerning injuries caused by Flash-Ball® shooting. However, we report the case of a healthy 34-year-old male victim of a Flash-Ball® shooting during a riot following a sports event. This young man presented serious craniocerebral injuries with a left temporal fracture, moderate cerebral oedema, fronto-temporal haemorrhagic contusion along with an extra-dural hematoma and subarachnoid hemorrhage requiring neurological and rehabilitation care for two months leaving important sequelae. Although the risk is obviously lower than with firearms, Flash-Ball® is nonetheless potentially lethal and may cause serious physical injuries, particularly after a shot to the head. © The Author(s) 2015.
Al-Essa, Rakan S; Aljahdali, Fares H; Alkhilaiwi, Rakan M; Philip, Winnie; Jawadi, Ayman H; Khoshhal, Khalid I
Developmental dysplasia of the hip (DDH) is one of the prevalent musculoskeletal conditions in young adults and is a leading cause of hip osteoarthrosis in this age group. The optimum age for surgical intervention when needed is not well established in the literature and the lack of management guidelines and standard practice of DDH leads to different practices worldwide. This study aims to investigate the current practice of paediatric orthopaedic surgeons in diagnosing and treating DDH worldwide and identify points of agreement and disagreement. A cross-sectional study utilizing an online questionnaire was designed to examine the different points of view and current practice of paediatric orthopaedic surgeons worldwide regarding DDH diagnosis and treatment. Ninety-one surgeons responded, with an overall response of 45.5%. The vast majority of respondents use ultrasonography in children less than 3 months of age and pelvic radiography in over 3 months to diagnose DDH. Pavlik harness is the most popular DDH treatment for children younger than 6 months. For older children, closed reduction with hip spica cast is the most preferable treatment. The maximum duration of first-line treatment has a broad range. The treatment of bilateral DDH varies widely among surgeons. This study shows clearly that paediatric orthopaedic surgeons do not agree on the diagnosis and treatment protocol of DDH, hence different approaches to this common disease are practised. The lack of an international guideline should motivate paediatric orthopaedic surgeons to discuss and formulate a uniform and evidence-based protocol for the diagnosis and treatment of DDH.
Achondroplasia and hypochondroplasia are the most common forms of short stature. The leading sign is the diminished body height. Most cases of achondroplasia can be detected by clinical examination. Hypochondroplasia is more often not diagnosed until preschool age.In achondroplasia many different orthopaedic problems can arise, which influence the ADL. Mainly pathologic alterations of the occipitocervical region or a stenosis of the medullary cavity should be expected. In the limbs a bow-leg deformity and hyperlaxity of the ligaments often can be seen, which in some cases restrict walking capacity. Even if many people of short stature contemplate a lengthening procedure, the correction of deformities is much more important. The CORA method should be used in planning any osteotomy.