Impact of demonstration in a realistic simulation environment as a postoperative education in patients' experience

OBJECTIVE

To evaluate the impact of training in the Practical Life Room on patients experience during hospitalization.

METHODS

Subjects submitted to orthopedic surgeries were randomized to two groups (Control and Intervention) in the postoperative period. The Control Group received only the printed guidelines regarding the postoperative period, and the Intervention Group received the printed guidelines and a demonstration and training session with a physical therapist, in an environment created to simulate a house and its rooms (living room, bedroom, kitchen, laundry and bathroom). The participants of both groups answered the questionnaire Hospital Consumer Assessment of Healthcare Providers and Systems on the day of discharge.

RESULTS

Sixty-eight subjects were included in the study, 30 (44.1%) in the Control Group and 38 (55.9%) in the Intervention Group. The Hospital Consumer Assessment of Healthcare Providers and Systems questionnaire score showed no significant difference between the groups (p=0.496).

CONCLUSION

There was no influence of the proposed intervention on the results of the Hospital Consumer Assessment of Healthcare Providers and Systems questionnaire, perhaps because of the limitation of the instrument or due to the fact it was employed when patients were still hospitalized. However, by reports from patients in the Intervention Group about felling better prepared and safer for performing daily activities, it is believed that patient education approaches through demonstration should be included as part of the process to prepare for discharge, whenever possible.

Hospitals´ Discharge Tendency and Risk of Death - An Analysis of 60,000 Norwegian Hip Fracture Patients

Purpose

A reduction in the length of hospital stay may threaten patient safety. This study aimed to estimate the effect of organizational pressure to discharge on 60-day mortality among hip fracture patients.

Patients and Methods

In this cohort study, hip fracture patients were analyzed as if they were enrolled in a sequence of trials for discharge. A hospital’s discharge tendency was defined as the proportion of patients with other acute conditions who were discharged on a given day. Because the hospital’s tendency to discharge would affect hip fracture patients in an essentially random manner, this exposure could be regarded as analogous to being randomized to treatment in a clinical trial. The study population consisted of 59,971 Norwegian patients with hip fractures, hospitalized between 2008 and 2016, aged 70 years and older. To calculate the hospital discharge tendency for a given day, we used data from all 5,013,773 other acute hospitalizations in the study period.

Results

The probability of discharge among hip fracture patients increased by 5.5 percentage points (95% confidence interval (CI)=5.3–5.7) per 10 percentage points increase in hospital discharges of patients with other acute conditions. The increased risk of death that could be attributed to a discharge from organizational causes was estimated to 3.7 percentage points (95% CI=1.4–6.0). The results remained stable under different time adjustments, follow-up periods, and age cut-offs.

Conclusion

This study showed that discharges from organizational causes may increase the risk of death among hip fracture patients.

Arthroscopic Bristow: Assessments of Safety and Effectiveness, 12 Years of Experience

Objective  The open Bristow procedure is a long established and effective method for treating anterior shoulder instability. Following the trends of minimally-invasive surgeries, these procedures were performed arthroscopically, and their outcomes were evaluated.

Methods  A total of 43 shoulders of patients submitted to Bristow procedures by arthroscopy, using a graft positioned horizontally and a screw, with at least two years of postoperative follow-up, were evaluated regarding quality of life, de novo dislocation index, and loss of lateral rotation.

Results  The mean follow-up time was of 76 months (range: 129 to 24 months). The University of California at Los Angeles (UCLA) score varied from 25.56 ± 0.50 (standard deviation [SD] = 3.25) to 33.23 ± 0.44 (SD = 2.91) ( p  < 0.0001). Two or more years after surgery, the mean Rowe score was of 94.25 ± 1.52 (SD = 1.34), whereas the good results standard is 75 ( p  < 0.0001). The mean value for the simple shoulder test was of 11.35 ± 0.21 (SD = 1.34), while the mean value of the lateral rotation loss was of 10.37° ± 1.36° (SD = 8.58°). There were no de novo dislocations.

In total, there were 12 complications, 8 of which had no clinical repercussions. The clinically-significant complications included an infection six months after surgery with a potential hematogenous origin, a coracoid fracture that required an intraoperatively procedure change, and two patients with previous impingement who required synthesis material removal more than six months after surgery.

Conclusion  Although the arthroscopic Bristow procedure was effective in treating anterior shoulder instability, it is not a complication-free surgery.

Anatomical Variability of Intercondylar Fossa Geometry in Patients Diagnosed with Primary Anterior Cruciate Ligament Rupture

The aims of this study were to (1) describe the three-dimensional characteristics and sources of anatomical variability in the geometry of the intercondylar fossa ("notch") in an anterior cruciate ligament (ACL)-injured sample and (2) assess the relationship between patient factors and anatomical variability of the fossa in the context of impingement risk. A retrospective analysis of preoperative magnetic resonance imaging (MRI) for 49 patients with ACL rupture was performed. Scans were examined in the axial plane using an online picture archiving and communication system (PACS) viewer and fossa width and angle assessed at multiple slices, as well as anteroposterior depth, fossa height, and calculated total volume. Principal component analysis was performed to prioritize the sources of variability. A multivariate linear regression was performed to assess relationships between different patient factors, controlling for imaging parameters and principal component loadings. Geometric properties were normally distributed for all but fossa volume, height, and distal angle. Three principal components (PCs) were identified explaining 80% of total variance, shape (PC1), size in the coronal plane (PC2), and size in the sagittal plane (PC3). Patient factors were significantly (P < 0.05) related to PC loadings; however, a substantial amount of variance in each model remained unexplained. Intercondylar fossa characteristics vary considerably within ACL-injury patients with shape and size in coronal and axial planes, explaining most of the variance. Although patient factors are associated with anatomical characteristics, further work is required to identify the correct combination of factors accurately predicting geometry of the fossa for planning ACL reconstruction. Clin. Anat. 33:610-618, 2020. © 2019 Wiley Periodicals, Inc.

Psoriatic arthritis - new perspectives

Psoriatic arthritis (PsA) is a seronegative arthropathy with many clinical manifestations, and it may affect nearly a half of patients with psoriasis. PsA should be diagnosed as early as possible to slow down joint damage and progression of disability. To improve the diagnosis of PsA, physicians should look for peripheral inflammatory pain, axial inflammatory pain, dactylitis, and buttock and sciatic pain. In most patients with PsA, pharmacologic treatment with non-steroidal anti-inflammatory drugs, disease-modifying anti-rheumatic drugs, and biologic agents is effective. However, when pharmacological treatment fails, patients with PsA may benefit from orthopedic surgery, which can improve both joint function and quality of life. Total hip arthroplasty, total knee arthroplasty, and arthroscopic synovectomy of the knee are the most common surgical procedures offered to patients with PsA. The management of PsA requires the care of a multidisciplinary team, which should include dermatologists, rheumatologists, physiotherapists, and orthopedic surgeons.

Biomechanical Evaluation of Different Tibial Fixation Methods in the Reconstruction of the Anterolateral Ligament in Swine Bones

Objective  The present study aims to evaluate different methods of tibial fixation in the reconstruction of the anterolateral ligament (ALL). In addition, the present paper aims to compare the effectiveness of these methods and their mechanisms of failure in swine knees. Methods  A total of 40 freshly frozen swine limbs were divided into 4 groups of 10 specimens, according to the tibial fixation technique used. In group A, the tibial fixation of the tendon graft was made through an anchor passing the graft. In group B, the tibial fixation was performed through a metal interference screw in a single bone tunnel. In group C, the tibial fixation included an anchor associated with a tendinous suture (but not with a wire crossing the tendon). In group D, two confluent bony tunnels were drilled and combined with an interference screw in one of them. Results  The lowest mean force (70.56 N) was observed in group A, and the highest mean force (244.85 N) was observed in group B; the mean values in the other 2 groups ranged from 171.68 N (group C) to 149.43 N (group D). Considering the margin of error (5%), there was a significant difference between the groups ( p  < 0.001). Conclusion  Fixation with an interference screw in a single tunnel bone showed the highest tensile strength among the evaluated techniques.

Impact of enhanced recovery after surgery on postoperative recovery after joint arthroplasty: results from a systematic review and meta-analysis

STUDY DESIGN

Systematic review with meta-analysis.

OBJECTIVES

To evaluate the effects of enhanced recovery after surgery (ERAS) on the postoperative recovery of patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

The PubMed, Embase, Cochrane and ISI Web of Science databases were searched to identify literature including randomised controlled trials (RCTs), cohort studies and case-control studies through 2 May 2018. The analysed outcomes were mortality rate, transfusion rate, range of motion (ROM), 30-day readmission rate, postoperative complication rate and in-hospital length of stay (LOS).

RESULTS

A total of 25 studies involving 16 699 patients met the inclusion criteria and were included in the meta-analysis. Compared with conventional care, ERAS was associated with a significant decrease in mortality rate (relative risk (RR) 0.48, 95% CI 0.27 to 0.85), transfusion rate (RR 0.43, 95% CI 0.37 to 0.51), complication rate (RR 0.74, 95% CI 0.62 to 0.87) and LOS (mean difference (MD) -2.03, 95% CI -2.64 to -1.42) among all included trials. However, no significant difference was found in ROM (MD 7.53, 95% CI -2.16 to 17.23) and 30-day readmission rate (RR 0.86, 95% CI 0.56 to 1.30). There was no significant difference in complications of TKA (RR 0.84, 95% CI 0.34 to 2.06) and transfusion rate in RCTs (RR 0.66, 95% CI 0.15 to 2.88) between the ERAS group and the control group.

CONCLUSIONS

This meta-analysis showed that ERAS significantly reduced the mortality rate, transfusion rate, incidence of complications and LOS of patients undergoing TKA or THA. However, ERAS did not show a significant impact on ROM and 30-day readmission rate. Complications after hip replacement are less than those of knee replacement, and the young patients recover better.

LEVEL OF EVIDENCE

Level 1.

Effect of the support systems' compliance on total hip modular taper seating stability

Assembly of a femoral head onto the stem remains non-standardized. The literature shows altering mechanical conditions during seating affects taper strength and lower assembly load may increase fretting corrosion during cyclic tests. This suggests overall performance may be affected by head assembly method. The purpose of this test was to perform bench-top studies to determine influence of peak force magnitude, load rate, and compliance of the system's support structure on initial stability of the taper. Custom manufactured CoCrMo femoral heads and Ti-6Al-4V taper analog samples were assembled with varying peak force magnitudes (2-10.1 kN), load rates (quasi-static vs impaction), and system compliance (rigid vs compliant). A clinically-relevant system compliance design was based off of force data collected during a cadaver impaction study. Tensile loads were then applied to disassemble the taper and quantify initial taper stability. Results indicated that taper stability (assessed by disassembly forces) increased linearly with assembly force and load rate did not have a significant effect on taper stability. When considering system compliance, a 42%-50% larger input energy, dependent on assembly force, was required in the compliant group to achieve a comparable impaction force to the rigid group. Even when this impaction force was achieved, the correlation between the coefficient, defined as distraction force divided by assembly load, was significantly reduced for the compliant test group. The compliant setup was intended to simulate a surgical scenario where patient and surgical factors may influence the resulting compliance. Based on results, surgical procedure and patient variables may have a significant effect on initial taper stability.

[Erythropoietin and blood loss in selected orthopedic procedures]

Orthopedic surgical procedures, especially in the lower limbs, are associated with a high risk of massive bleeding and, consequently, the development of anemia and the need for blood transfusions and its preparations. This creates the need to look for effective methods of prevention and treatment of anemia that will be safe for the patient and reduce the cost of treatment. One of the most common methods of limiting the allogenic blood usage in orthopedic procedures is the use of autologus transfusions. In addition to many benefits, they may contribute to the patient's anemia, which is a serious health problem in the post-operative period. Analyzed data from the literature indicate that the use of recombinant human erythropoietin significantly reduces the need for blood transfusion in the perioperative period and may reduce the cost of treatment.

Femoral Component Axial Rotation in the Gap-Balancing Approach to Total Knee Arthroplasty: Measurement by Computed Tomography

BACKGROUND

Rotational malalignment of total knee arthroplasty (TKA) is a potential cause for revision surgery; therefore, it is important to have valid criteria for evaluation of normal component rotational alignment. Because computed tomography (CT) is considered the most accurate method to assess the rotational alignment of prosthetic components, the objectives in this study were define the femoral component (FC) rotation by measuring the posterior condylar angle (PCA) and the condylar twist angle (CTA) in a patient population that underwent gap-balancing TKA; determine the reliability of the FC rotation by using these measurements; evaluate the inter-relationship between the PCA and CTA; and finally evaluate the frequency and agreement in identification of the medial epicondyle sulcus (MES).

METHODS AND RESULTS

In this retrospective study, 2 radiologists examined 50 CT scans. Mean PCA values of -2.26° and -2.56° (internal rotation) and CTA values of -5.54° and -6.28° (internal rotation) were attained by 2 observers with a higher interobserver concordance for the PCA. Both measurements were considered to be reliable. There was moderate interobserver agreement for MES identification, with the MES present in 64% and 78% of patients, as identified by 2 observers.

CONCLUSION

Mean FC rotation values as evaluated by PCA were -2.26° and -2.56° and as evaluated by CTA were -5.54° and -6.28°. PCA and CTA measurement by CT is reliable; however, the use of PCA is preferable because of the higher observer concordance. PCA can be inferred by subtracting 3° or 4° from the CTA. MES was identified in 64% and 78% of patients, with only moderate interobserver agreement.

A model to evaluate Pauwels type III femoral neck fractures

While many femoral neck fractures can be reliably treated with surgical intervention, Pauwels III femoral neck fractures in the young adult population continue to be a challenging injury, and there is no consensus on optimal treatment. As such, there are past and ongoing biomechanical studies to evaluate the fixation provided by different constructs for this inherently unstable fracture. While many investigations rely on cadavers to evaluate the biomechanical performance of a construct, significant inter-subject variability can confound the analysis. Biomechanical femur analogs are being used more frequently due to more consistent mechanical properties; however, they have not been stringently evaluated for morphology or suitability for instrumentation. This study sought to determine the variability among composite femoral analogs as well as consistently create a Pauwels III injury and instrument the analogs without the need for fluoroscopic guidance. In total, 24 fourth-generation composite femoral analogs were evaluated for femoral height, neck-shaft angle, anteversion, and cortical thickness. A method was developed to simulate a Pauwels III fracture and to prepare three different constructs: an inverted triangle of cannulated screws, a sliding hip screw, and a hybrid inverted triangle with cannulated screws and a sliding hip screw. Radiographs were utilized to evaluate the variation in implant position. All but one of the morphological parameters varied by <1%. The tip-to-apex distance for all sliding hip screw hardware was 18.8 ± 3.3 mm, and all relevant cannulated screw distances were within 5 mm of the adjacent cortex. All screws were parallel, on average, within 1.5° on anterior-posterior and lateral films. Fourth-generation composite femora were found to be morphologically consistent, and it is possible to consistently instrument the analogs without the use of fluoroscopy. This analog and hardware implantation model could serve as a screening model for new fracture repair constructs without the need for cadaveric tissues or radiologic technology.

Increased stress and strain on the spinal cord due to ossification of the posterior longitudinal ligament in the cervical spine under flexion after laminectomy

Myelopathy in the cervical spine due to cervical ossification of the posterior longitudinal ligament could be induced by static compression and/or dynamic factors. It has been suggested that dynamic factors need to be considered when planning and performing the decompression surgery on patients with the ossification of the posterior longitudinal ligament. A finite element model of the C2-C7 cervical spine in the neutral position was developed and used to generate flexion and extension of the cervical spine. The segmental ossification of the posterior longitudinal ligament on the C5 was assumed, and laminectomy was performed on C4-C6 according to a conventional surgical technique. For various occupying ratios of the ossified ligament between 20% and 60%, von-Mises stresses, maximum principal strains in the spinal cord, and cross-sectional area of the cord were investigated in the pre-operative and laminectomy models under flexion, neutral position, and extension. The results were consistent with previous experimental and computational studies in terms of stress, strain, and cross-sectional area. Flexion leads to higher stresses and strains in the cord than the neutral position and extension, even after decompression surgery. These higher stresses and strains might be generated by residual compression occurring at the segment with the ossification of the posterior longitudinal ligament. This study provides fundamental information under different neck positions regarding biomechanical characteristics of the spinal cord in cervical ossification of the posterior longitudinal ligament.

Direct medial approach in surgical fixation of fractures in the posterior aspect of the medial malleolus

Fractures in the posterior aspect of the medial malleolus form an important subset of ankle fractures and the indications for fixation include involvement of > 25% of the articular surface or an articular step off by > 2 mm. Several approaches have been described but there has been no recent study on the direct medial approach. Five fresh frozen cadaveric ankles were dissected using the direct medial approach. A longitudinal incision of 10 cm was centered directly over the medial malleolus and deepened straight down to the bone. The periosteum was identified over the distal tibia and careful subperiosteal dissection yielded access to the posterior aspect of the medial malleolus. We investigated the relationship of the neurovascular bundle to the incision by measuring the distance from the center of the medial malleolus to the closest aspect of the bundle. The mean distance from the center of the medial malleolus to the neurovascular bundle was only 2.64 cm (95% CI: 2.06 to 3.22 cm). We found that the neurovascular bundle could be avoided if a periosteal sheath was developed during the dissection and elevated off the posterior aspect of the medial malleolus. The direct medial approach can be performed safely by creating a periosteal sheath through subperiosteal dissection, and the distance of the neurovascular bundle from the incision allows for a good margin of safety during surgery. This approach can be extended proximally and distally and the medial malleolus can be fixed concurrently. Clin. Anat. 31:605-607, 2018. © 2017 Wiley Periodicals, Inc.

Surgical dislocation of the hip without trochanteric osteotomy

BACKGROUND

Surgical dislocation of the hip remains an important alternative in hip preservation surgery, especially when a dynamic access to the hip is needed and arthroscopy is not a suitable option. We describe a novel technique for operative dislocation of the hip without trochanteric osteotomy and the clinical results of our patients.

METHODS

Surgical dislocation of the hip without trochanteric osteotomy was done through a modified lateral approach in all of the cases. A review of demographic, clinical, and radiological data was done in all of the patients operated with this technique between 2010 and 2015. Complications, walking aids, weight-bearing status, and modified Harris Hip Score (mHHS) were also recorded.

RESULTS

Six surgical dislocations of the hip were carried out. Indications were tumor resection in five and bulletectomy in one hip. There were two women (four hips) and two men. Mean age was 19 ± 3.8 years. Median follow-up was 2.5 years (range 2-4.5 years). Median mHHS was 92 (90-96). There were no intraoperative nor postoperative complications.

CONCLUSIONS

Surgical dislocation of the hip without trochanteric osteotomy through a modified lateral approach appears to be a safe, simpler, and effective alternative.

Comparison of Frailty Measures as Predictors of Outcomes After Orthopedic Surgery

OBJECTIVES

To apply the Frailty Phenotype (FP) and Frailty Index (FI) before major elective orthopedic surgery to categorize frailty status and assess associations with postoperative outcomes.

DESIGN

Prospective cohort study.

SETTING

Two tertiary hospitals in Boston, Massachusetts.

PARTICIPANTS

Individuals aged 70 and older undergoing scheduled orthopedic surgery enrolled in the Successful Aging after Elective Surgery (SAGES) Study (N = 415).

MEASUREMENTS

Preoperative evaluation included assessment of frailty using the FP and FI. The weighted kappa statistic was used to determine concordance between the two frailty measures and multivariable modeling to determine associations between each measure and postoperative complications, postoperative length of stay (LOS) of longer than 5 days, discharge to postacute institutional care (PAC), and 300 day readmission.

RESULTS

Frailty was highly prevalent (FP, 35%; FI, 41%). There was moderate concordance between the FP and FI (κ = 0.42, 95% confidence interval (CI) 0.36-0.49). When using the FP, being prefrail predicted greater risk of complications (relative risk (RR) = 1.6, 95% CI = 1.1-2.1) and discharge to PAC (RR = 1.8, 95% CI = 1.2-2.9) than being robust, and being frail predicted more complications (RR = 1.7, 95% CI = 1.1-2.1), LOS longer than 5 days (RR = 3.1, 95% CI = 1.1-8.8), and discharge to PAC (RR = 2.3 95% CI = 1.4-3.7). When using FI, being prefrail predicted LOS longer than 5 days (RR = 2.1, 95% CI = 1.0-4.8) and discharge to PAC (RR = 1.5, 95% CI = 1.4-2.1), as did being frail (RR = 1.9, 95% CI = 1.4-2.5; RR = 3.1, 95% CI = 1.4-6.8, respectively). The other outcomes were not significantly associated with frailty status.

CONCLUSION

FP and FI predict postoperative outcomes after major elective orthopedic surgery and should be considered for preoperative risk stratification.

Evaluation of surgical impaction technique and how it affects locking strength of the head-stem taper junction

Cases of fretting and corrosion at the taper junction have been reported in large metal-on-metal bearing combinations, and more recently, this concern has included metal-on-polyethylene bearing combinations. Many of these patients have been revised due to adverse local tissue reaction secondary to taper corrosion. This taper corrosion-related adverse local tissue reaction seems to be a multifactorial issue and difficult to assess. The aim of this study was to look at one potential variable, the impaction behavior (impaction force, number of blows, etc.) of orthopedic surgeons, and understand how this can affect the locking strength of tapers. A group of experienced orthopedic surgeons were asked to use their typical surgical approach to impact a femoral head onto a hip femoral stem using an Operating Room (OR)-simulated test setup. Impaction parameters such as impaction force, velocity, and energy, as well as the number of impacts, were characterized and applied in a bench-top study used to evaluate the effect of these parameters on the initial stability of the taper junction. High variation was found in the surgical impaction parameters, but overall it was determined that increased impaction force correlated to superior stability of the taper junction.

Single versus double blade technique for skin incision and deep dissection in surgery for closed fracture: a prospective randomised control study

PURPOSE

To compare blade cultures in surgery for closed fracture using a single or double blade technique to determine whether the current practice of double blade technique is justified.

METHODS

155 men and 29 women aged 20 to 60 (mean, 35) years who underwent surgery for closed fracture with healthy skin at the incision site were included. Patients were block randomised to the single (n=92) or double (n=92) blade technique. Blades were sent for bacteriological analysis. Outcome measures were early surgical site infection (SSI) within 30 days and cultures from the blades.

RESULTS

The 2 groups were comparable in baseline characteristics. In the single blade group, 6 surgical blades and 2 control blades showed positive cultures; 4 patients developed SSI, but only one had a positive culture from the surgical blade (with different organism isolated from the wound culture). In the double blade group, 6 skin blades, 7 deep blades, and 0 control blade showed positive culture; only 2 patients had the same bacteria grown from both skin and deep blade. Five patients developed SSI, but only one patient had a positive culture from the deep blade (with different organism isolated from the wound culture). The difference in incidence of culture-positive blade or SSI between the 2 groups was not significant. The relative risk of SSI in the single blade group was 0.8. Positive blade culture was not associated with SSI in the single or double blade group.

CONCLUSION

The practice of changing blade following skin incision has no effect on reducing early SSI in surgery for closed fracture in healthy patients with healthy skin.

Patient refusal for regional anesthesia in elderly orthopedic population: A cross-sectional survey at a tertiary care hospital

Background and Aims:

Improvements in pain management techniques in the last decade have had a major impact on the practice of orthopedic surgeries, for example, total hip arthroplasty and total knee arthroplasty. Although there are a number of treatment options for postoperative pain, a gold standard has not been established. In our institution, both general anesthesia and regional anesthesia (RA), are being offered to the elderly orthopedic population but RA is not frequently accepted by elderly population. The objective of this study was to determine the frequency of various reasons for refusal of RA in elderly patients undergoing orthopedic surgeries.

Material and Methods:

A prospective study conducted over a period of 1 year, had 549 patients with ages above 60 years who underwent different types of elective orthopedic procedures 182 patients who refused RA were interviewed according to a structured questionnaire designed to assess the reasons of refusal.

Results:

Most common reason for the refusal of RA was surgeon's choice (38.5%), whereas 20.3% of the patients were unaware about the RA. There was a significant association between female gender and refusing RA due to backache (17.2%) and fear of being awake during the operation (24.1%) respectively.

Conclusion:

This survey showed that the main reasons among elderly female population were the fear of remaining awake and backache. However, overall it was the surgeon's choice which made patients refuse RA, and the anesthesiologists were the main source of information.

Effect of posterior decompression extent on biomechanical parameters of the spinal cord in cervical ossification of the posterior longitudinal ligament

Ossification of the posterior longitudinal ligament is a common cause of the cervical myelopathy due to compression of the spinal cord. Patients with ossification of the posterior longitudinal ligament usually require the decompression surgery, and there is a need to better understand the optimal surgical extent with which sufficient decompression without excessive posterior shifting can be achieved. However, few quantitative studies have clarified this optimal extent for decompression of cervical ossification of the posterior longitudinal ligament. We used finite element modeling of the cervical spine and spinal cord to investigate the effect of posterior decompression extent for continuous-type cervical ossification of the posterior longitudinal ligament on changes in stress, strain, and posterior shifting that occur with three different surgical methods (laminectomy, laminoplasty, and hemilaminectomy). As posterior decompression extended, stress and strain in the spinal cord decreased and posterior shifting of the cord increased. The location of the decompression extent also influenced shifting. Laminectomy and laminoplasty were very similar in terms of decompression results, and both were superior to hemilaminectomy in all parameters tested. Decompression to the extents of C3-C6 and C3-C7 of laminectomy and laminoplasty could be considered sufficient with respect to decompression itself. Our findings provide fundamental information regarding the treatment of cervical ossification of the posterior longitudinal ligament and can be applied to patient-specific surgical planning.

Point-of-Care Ultrasound Diagnosis of Deep Space Hand Infection

BACKGROUND

Point-of-care ultrasound is emerging as an important imaging modality for characterizing soft-tissue infections and provides advantages over physical examination and magnetic resonance imaging (MRI).

CASE REPORT

A 30-year-old man presented to the emergency department with extensive left upper extremity cellulitis. Magnetic resonance imaging of the left arm was preliminarily interpreted as soft-tissue swelling without evidence of deep-space infection. Point-of-care ultrasound revealed pockets of fluid with sonographic fluctuance tracking along the tendon sheath that were concerning for deep abscesses. Based on the ultrasound findings, the patient was taken emergently to the operating room, where multiple left hand and wrist loculated deep-space abscesses were decompressed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report highlights the significant advantages and easy-to-learn findings present in point-of-care ultrasound of musculoskeletal infections.

Redefining the Economics of Geriatric Orthopedics

Introduction:

The heath care system in the United States is in the midst of a transition, in large part to help accommodate an older and more medically complex population. Central to the current evolution is the reassessment of value based on the cost utility of a particular procedure compared to alternatives. The existing contribution of geriatric orthopedics to the societal burden of disease is substantial, and literature focusing on the economic value of treating elderly populations with musculoskeletal injuries is growing.

Materials and Methods:

A literature review of peer-reviewed publications and abstracts related to the cost-effectiveness of treating geriatric patients with orthopedic injuries was carried out.

Results:

In our review, we demonstrate that while cost-utility studies generally demonstrate net society savings for most orthopedic procedures, geriatric populations often contribute to negative net society savings due to decreased working years and lower salaries while in the workforce. However, the incremental cost-effective ratio for operative intervention has been shown to be below the financial willingness to treat threshold for common procedures including joint replacement surgery of the knee (ICER US$8551), hip (ICER US$17 115), and shoulder (CE US$957) as well as for spinal procedures and repair of torn rotator cuffs (ICER US$12 024). We also discuss the current trends directed toward improving institutional value and highlight important complementary next steps to help overcome the growing demands of an older, more active society.

Conclusion:

The geriatric population places a significant burden on the health care system. However, studies have shown that treating this demographic for orthopedic-related injuries is cost effective and profitable for providers under certain scenarios.

Introducing a New Technique for Limb Prepping in Orthopedic Surgeries: Designing, Construction, and Evaluation of Limb-Lifting Assistive Device

Lifting and holding patients' limbs while preparing the skin for orthopedic surgeries may be a lengthy process causing work-related musculoskeletal disorders (MSDs) for preoperative team members. Studies reported weight limits for lifting and holding limbs; whenever this weight is greater than a specific amount, additional staff or assistive devices are needed because nurses and support staff working in orthopedic operating rooms (ORs) are at high risk of MSDs. The aim of this study was to demonstrate the design, construction, and effectiveness of a limb-lifting assistive device installed in the OR of 5 Azar Hospital affiliated with Golestan University of Medical Sciences and used during the surgical preparation process.

Economic analysis of surgical treatment of hip fracture in older adults

OBJECTIVE To analyze the incremental cost-utility ratio for the surgical treatment of hip fracture in older patients. METHODS This was a retrospective cohort study of a systematic sample of patients who underwent surgery for hip fracture at a central hospital of a macro-region in the state of Minas Gerais, Southeastern Brazil between January 1, 2009 and December 31, 2011. A decision tree creation was analyzed considering the direct medical costs. The study followed the healthcare provider's perspective and had a one-year time horizon. Effectiveness was measured by the time elapsed between trauma and surgery after dividing the patients into early and late surgery groups. The utility was obtained in a cross-sectional and indirect manner using the EuroQOL 5 Dimensions generic questionnaire transformed into cardinal numbers using the national regulations established by the Center for the Development and Regional Planning of the State of Minas Gerais. The sample included 110 patients, 27 of whom were allocated in the early surgery group and 83 in the late surgery group. The groups were stratified by age, gender, type of fracture, type of surgery, and anesthetic risk. RESULTS The direct medical cost presented a statistically significant increase among patients in the late surgery group (p < 0.005), mainly because of ward costs (p < 0.001). In-hospital mortality was higher in the late surgery group (7.4% versus 16.9%). The decision tree demonstrated the dominance of the early surgery strategy over the late surgery strategy: R$9,854.34 (USD4,387.17) versus R$26,754.56 (USD11,911.03) per quality-adjusted life year. The sensitivity test with extreme values proved the robustness of the results. CONCLUSIONS After controlling for confounding variables, the strategy of early surgery for hip fracture in the older adults was proven to be dominant, because it presented a lower cost and better results than late surgery.

Conservative surgery for the treatment of osteonecrosis of the femoral head: current options

The prevention of femoral head collapse and the maintenance of hip function would represent a substantial achievement in the treatment of osteonecrosis of the femoral head; however it is difficult to identify appropriate treatment protocols to manage patients with pre-collapse avascular necrosis in order to obtain a successful outcome in joint preserving procedures. Conservative treatments, including pharmacological management and biophysical modalities, are not supported by any evidence and require further investigation. The appropriate therapeutic approach has not been identified. The choice of surgical procedures is based on patient clinical conditions and anatomopathological features; preservation of the femoral head by core decompression may be attempted in younger patients without head collapse. Biological factors, such as bone morphogenetic proteins and bone marrow stem cells, would improve the outcome of core decompression. Another surgical procedure proposed for the treatment of avascular necrosis consists of large vascularized cortical bone grafts, but its use is not yet common due to surgical technical issues. Use of other surgical technique, such as osteotomies, is controversial, since arthroplasty is considered as the first option in case of severe femoral head collapse without previous intervention.

Surgical approaches for cervical spine facet dislocations in adults

BACKGROUND

The choice of surgical approach for the management of subaxial cervical spine facet dislocations is a controversial subject amongst spine surgeons. Reasons for this include differences in the technical familiarity and experience of surgeons with the different surgical approaches, and variable interpretation of image studies regarding the existence of a traumatic intervertebral disc herniation and of the neurological status of the patient. Moreover, since the approaches are dissimilar, important variations are likely in neurological, radiographical and clinical outcomes.

OBJECTIVES

To compare the effects (benefits and harms) of the different surgical approaches used for treating adults with acute cervical spine facet dislocation.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (9 May 2014), The Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014 Issue 4), MEDLINE (1946 to April Week 5 2014), MEDLINE In-Process & Other Non-Indexed Citations (8 May 2013), EMBASE (1980 to 2014 Week 18), Latin American and Caribbean Health Sciences (9 May 2014), trial registries, conference proceedings and reference lists of articles to May 2014.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared surgical approaches for the management of adults with acute cervical spine facet dislocations with and without spinal cord injury.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias and extracted data.

MAIN RESULTS

We included one randomised and one quasi-randomised controlled trial involving a total of 94 participants and reporting results for a maximum of 84 participants. One trial included patients with spinal cord injuries and the other included patients without spinal cord injuries. Both trials compared anterior versus posterior surgical approaches. Both trials were at high risk of bias, including selection bias (one trial), performance bias (both trials) and attrition bias (one trial). Data were pooled for one outcome only: non-union. Reflecting also the imprecision of the results, the evidence was deemed to be of very low quality for all outcomes; which means that our level of uncertainty about the estimates is high.Neither trial found differences between the two approaches in neurological recovery or status, as shown in one study by small clinically insignificant differences in NASS (Northern American Spine Society) neurological scores (0 to 100: optimal score) at one year of follow-up: anterior mean score: 85.23 versus posterior mean score: 83.86; mean difference (MD) 1.37 favouring anterior approach, 95% confidence interval (CI) -9.76 to 12.50; 33 participants; 1 study). The same trial found no relevant between-approach differences at one year in patient-reported quality of life measured using the 36-item Short Form Survey physical (MD -0.08, 95% CI -7.26 to 7.10) and mental component scores (MD 2.88, 95% CI -3.32 to 9.08). Neither trial found evidence of significant differences in long-term pain, or non-union (2/38 versus 2/46; risk ratio (RR) 1.18, 95% CI 0.04 to 34.91). One trial found better sagittal and more 'normal' alignment after the anterior approach (MD -10.31 degrees favouring anterior approach, 95% CI -14.95 degrees to -5.67 degrees), while the other trial reported no significant differences in cervical alignment. There was insufficient evidence to indicate between-group differences in medical adverse events, rates of instrumentation failure and infection. One trial found that the several participants had voice and swallowing disorders after anterior approach surgery (11/20) versus none (0/22) in the posterior approach group: RR 25.19, 95% CI 1.58 to 401.58); all had recovered by three months.

AUTHORS' CONCLUSIONS

Very low quality evidence from two trials indicated little difference in long-term neurological status, pain or patient-reported quality of life between anterior and posterior surgical approaches to the management of individuals with subaxial cervical spine facet dislocations. Sagittal alignment may be better achieved with the anterior approach. There was insufficient evidence available to indicate between-group differences in medical adverse events, rates of instrumentation failure and infection. The disorders of the voice and swallowing that occurred exclusively in the anterior approach group all resolved by three months. We are very uncertain about this evidence and thus we cannot say whether one approach is better than the other. There was no evidence available for other approaches. Further higher quality multicentre randomised trials are warranted.

Comparison of the effect of intravenous ketamine and intramuscular ketamine for orthopedic procedures in children's sedation

Background:

Ketamine is used as a general anesthetic for short-term surgical procedures. The aim of this study is to compare the effect of intravenous (IV) ketamine and intramuscular (IM) ketamine in children admitted to the emergency department (ED).

Materials and Methods:

This is a clinical trial on 60 patients who were randomly classified into two groups. The first group received IV ketamine (1 mg/kg) and the second received IM ketamine (4 mg/kg). Data were collected before, during, and after the procedure. Time to reach sedation, severity of the sedation, and complications of the drug until discharge were studied.

Results:

In this study, 60 patients were evaluated. The average length of the procedures was similar in both groups (P > 0.05). According to this study, sedation levels in the two groups in 5, 10, and 15 minutes did not show significant differences (P > 0.05), but there was a significant difference in sedation levels of patients in 30, 35, 40, and 45 minutes during sedation (P = 0.03, P = 0.04, P = 0.03 and P = 0.05). There was no significant difference in the incidence of complications between the two groups.

Dicussion:

There was no significant difference in complications and level of sedation in both groups, but sedation was longer in the IM group; so, IV ketamine is the desirable approach for orthopedic procedures in sedating children.

Orthodontic and orthopaedic treatment for anterior open bite in children

BACKGROUND

Anterior open bite occurs when there is a lack of vertical overlap of the upper and lower incisors. The aetiology is multifactorial including: oral habits, unfavourable growth patterns, enlarged lymphatic tissue with mouth breathing. Several treatments have been proposed to correct this malocclusion, but interventions are not supported by strong scientific evidence.

OBJECTIVES

The aim of this systematic review was to evaluate orthodontic and orthopaedic treatments to correct anterior open bite in children.

SEARCH METHODS

The following databases were searched: the Cochrane Oral Health Group's Trials Register (to 14 February 2014); the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library 2014, Issue 1); MEDLINE via OVID (1946 to 14 February 2014); EMBASE via OVID (1980 to 14 February 2014); LILACS via BIREME Virtual Health Library (1982 to 14 February 2014); BBO via BIREME Virtual Health Library (1980 to 14 February 2014); and SciELO (1997 to 14 February 2014). We searched for ongoing trials via ClinicalTrials.gov (to 14 February 2014). Chinese journals were handsearched and the bibliographies of papers were retrieved.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of orthodontic or orthopaedic treatments or both to correct anterior open bite in children.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of all reports identified. Risk ratios (RRs) and corresponding 95% confidence intervals (CIs) were calculated for dichotomous data. The continuous data were expressed as described by the author.

MAIN RESULTS

Three randomised controlled trials were included comparing: effects of Frankel's function regulator-4 (FR-4) with lip-seal training versus no treatment; repelling-magnet splints versus bite-blocks; and palatal crib associated with high-pull chincup versus no treatment.The study comparing repelling-magnet splints versus bite-blocks could not be analysed because the authors interrupted the treatment earlier than planned due to side effects in four of ten patients.FR-4 associated with lip-seal training (RR = 0.02 (95% CI 0.00 to 0.38)) and removable palatal crib associated with high-pull chincup (RR = 0.23 (95% CI 0.11 to 0.48)) were able to correct anterior open bite.No study described: randomisation process, sample size calculation, there was not blinding in the cephalometric analysis and the two studies evaluated two interventions at the same time. These results should be therefore viewed with caution.

AUTHORS' CONCLUSIONS

There is weak evidence that the interventions FR-4 with lip-seal training and palatal crib associated with high-pull chincup are able to correct anterior open bite. Given that the trials included have potential bias, these results must be viewed with caution. Recommendations for clinical practice cannot be made based only on the results of these trials. More randomised controlled trials are needed to elucidate the interventions for treating anterior open bite.

Occupational radiation exposure to anesthetists from fluoroscopic projections during orthopedic operative procedures

PURPOSE

The role of anesthetists during orthopedic fluoroscopic procedures exposes them to radiation. We conducted a prospective, descriptive study to estimate the radiation exposure to anesthetists during procedures over a six-month period in the orthopedic trauma operating theatres which had the most fluoroscopic usage.

MATERIALS AND METHODS

Thermoluminescent dosimeter (TLD) chips were placed two metres away from the radiation source, in three positions to simulate the anesthetist's position in the operating theatre during the fluoroscopic procedures as well as their radiation safety practices. The three positions were above the lead gown, behind the lead gown and behind the protective lead screen. The fourth TLD chip was assigned as a control measure to account for background radiation. The radiation exposure was measured at every end of each month during the period of six consecutive months. The TLD chips were sent to the Malaysian Institute for Nuclear Technology (MINT) for the analysis.

RESULTS

From the study, the annual exposure without a protective shield at a 2 metre distance from the projection source was estimated to be 0.70 milliSievert (mSv)/year. With the use of lead gowns and protective lead screens, the annual exposure was estimated to be 0.08 mSv / year. All the radiation levels measured were within the maximum permissible dose of 50 mSv / year.

CONCLUSIONS

During fluoroscopic assisted orthopedic procedures, the anesthetists in UKMMC are exposed to a small amount of radiation which is well below the annual maximum permissible limit as determined by local and international regulatory bodies.

Ultrasound-guided parasacral approach to the sciatic nerve block in children

BACKGROUND

The parasacral (PS) approach to sciatic nerve blockade has the potential for safe and effective use in children, but has never been studied in this population. Its potential advantages include increased posterior cutaneous nerve block reliability, potential for hip joint analgesia, and decreased nerve depth, making ultrasound guidance easier.

OBJECTIVE

To assess the efficacy of an ultrasound-guided PS sciatic nerve block in children.

METHODS

Nineteen patients, 1-16 years old, scheduled for lower limb surgery with peripheral nerve blockade (PNB) were prospectively enrolled. A PS sciatic block was performed using both ultrasound guidance and nerve stimulation, and 0.5 ml·kg(-1) ropivacaine 0.2% (maximum 20 ml) was administered. Patient demographics, the time to perform the block, the lowest intensity of nerve stimulation, evoked response, identification of gluteal arteries, and amount of narcotic given were recorded. Postoperatively, pain scores, block success or failure, block duration, and complications were recorded.

RESULTS

The block was performed using the PS approach in 95% of the cases. The success rate was 100% in the PS sciatic blocks performed. The pain scores for all patients in the first postsurgical hour were zero, except one patient that had a pain score of 3 of 10 at 30 min; his pain improved to 0 of 10 after administration of one dose of fentanyl and distraction techniques. The blocks lasted 17.3 ± 5.4 h. No complications were identified.

CONCLUSION

The PS approach is an effective option for sciatic nerve blockade to provide postoperative pain relief in children having lower extremity surgery.

Talonavicular joint arthrodesis for the treatment of pes planus valgus in older children and adolescents with cerebral palsy

PURPOSE

The purpose of this report is to review our experience with talonavicular joint arthrodesis for the treatment of severe valgus foot deformities in older children and adolescents with cerebral palsy (CP).

METHODS

The clinical, radiographic, and gait parameters results after talonavicular joint arthrodesis were retrospectively reviewed in 32 patients (59 feet) with valgus deformities of the foot. The surgery was performed as part of multiple simultaneous surgeries for the treatment of gait disorders. The mean age of the patients was 13.9 years (range 9-20 years) and the mean follow-up was 40 months (range 18.3-66.7 months).

RESULTS

The clinical and radiographic measurements improved significantly (P = 0.000). There were no significant changes in gait parameters. Symptoms were relieved in most patients with symptomatic preoperative feet. The most frequent complication was pseudoarthrosis, which occurred in seven feet. We found a high rate of satisfaction of patients (or parents) and most of them recommended the procedure to other patients with the same condition.

CONCLUSION

Talonavicular joint arthrodesis is a reliable technique that provides both functionally and cosmetically good results with a low rate of complications in the treatment of severe pes planus valgus in older children and adolescents with CP. Careful examination should rule out concomitant ankle valgus deformities. A stable fixation of the arthrodesis is recommended.

Continuous spinal anesthesia versus combined spinal epidural block for major orthopedic surgery: prospective randomized study

CONTEXT AND OBJECTIVES

In major orthopedic surgery of the lower limbs, continuous spinal anesthesia (CSA) and combined spinal epidural anesthesia (CSE) are safe and reliable anesthesia methods. In this prospective randomized clinical study, the blockading properties and side effects of CSA were compared with single interspace CSE, among patients scheduled for major hip or knee surgery.

DESIGN AND SETTING

Prospective clinical study conducted at the Institute for Regional Anesthesia, Hospital de Base, São José do Rio Preto.

METHODS

240 patients scheduled for hip arthroplasty, knee arthroplasty or femoral fracture treatment were randomly assigned to receive either CSA or CSE. Blockades were performed in the lateral position at the L3-L4 interspace. Puncture success, technical difficulties, paresthesia, highest level of sensory and motor blockade, need for complementary doses of local anesthetic, degree of technical difficulties, cardiocirculatory changes and postdural puncture headache (PDPH) were recorded. At the end of the surgery, the catheter was removed and cerebrospinal fluid leakage was evaluated.

RESULTS

Seven patients were excluded (three CSA and four CSE). There was significantly lower incidence of paresthesia in the CSE group. The resultant sensory blockade level was significantly higher with CSE. Complete motor blockade occurred in 110 CSA patients and in 109 CSE patients. Arterial hypotension was observed significantly more often in the CSE group. PDPH was observed in two patients of each group.

CONCLUSION

Our results suggest that both CSA and CSE provided good surgical conditions with low incidence of complications. The sensory blockade level and hemodynamic changes were lower with CSA.