[Necessity of development of Russian vertebrologic registry]

Development of national and international registers for the most socially significant diseases is an important problem of contemporary medicine. Importance and priority of vertebrological register is explained by relatively young age of spinal neurosurgery as specialty, in which many questions concerning indications and optimal methods of treatment remain unsolved, and accumulated experience is quite limited. Nevertheless, vertebrology is on the way from opinions of certain experts to evidence-based scientific proofs. This transition needs generally accepted and convenient instruments for assessment of outcomes of treatment and procedures which should be presented by national vertebrological register. Aims of its development include accumulation of clinically valuable resources and knowledge in vertebrology by means of organization of society of interested professionals and patients. The paper discusses architecture, contents and importance of development of Russian vertebrological register targeted on neurosurgeons, orthopaedic surgeons, vertebrologists and other specialists dealing with this problem. Foreign vertebrological registers are analyzed, their advantages and disadvantages are summarized, requirements for inclusion of criteria in the register are investigated.

[Elective orthopaedic surgery (EOS) in haemophilia. Proposals for optimizing and standardization]

In particular health economists promise to improve healthcare processes, cost-effectiveness and outcomes by standardised procedures. In the area of EOS indication, operative procedures and postal-surgical pain therapy can partly be standardised. In addition, clinical pathways have impact on the organisation of care if the care process is structured in a standardised way. On these four subjects examples are demonstrated. Elective orthopaedic surgery in haemophilia can be standardised. Nevertheless, it may not be forgotten that these patients can be categorised only restrictedly and the individual, interdisciplinary treatment must be prior to clinical standards.

Do scores of the USMLE Step 1 and OITE correlate with the ABOS Part I certifying examination?: a multicenter study

BACKGROUND

The US Medical Licensing Examination (USMLE) and Orthopaedic In-Training Examination (OITE) are commonly used to select medical students or residents, respectively. Knowing how well these examinations predict performance on the American Board of Orthopaedic Surgery (ABOS) Part I certifying examination is important to provide evaluations for medical students and residents. Previous studies comparing the OITE scores with the ABOS Part 1 scores have been limited to one program.

QUESTIONS/PURPOSES

Therefore, we compared the scores on the USMLE Step 1 and OITE examinations with those on the ABOS Part I certifying examination using data from four ACGME approved residency programs.

METHODS

We reviewed 202 resident files from 1996 to 2008 from four programs in the same geographic region. Of those, 181 (90%) had complete records. De-identified data were used to compare USMLE Step 1 scores, OITE percentile rank scores, and ABOS Part I percentile rank scores. Pearson coefficients and receiver operator curves were calculated to assess the relationships between tests.

RESULTS

We found a correlation of 0.53 between the USMLE Step 1 and ABOS Part I, and an average correlation of 0.50 for postgraduate years (PGY) 2 through 5 OITE scores and ABOS Part I. There was a stepwise increase in correlation from PGY 2 through PGY 5 between the OITE scores and ABOS scores. Those who averaged in the 27th percentile or lower on the OITE had a 57% chance of failing the ABOS Part I examination.

CONCLUSION

USMLE Step 1 scores correlated with ABOS Part I certifying examination scores, and we therefore believe it may be used as one factor in resident selection. Use of the OITE scores in guiding education and feedback appears to be justified.

[Early or delayed peripheral surgery in patients with severe head injury?]

Head injuries are present in up to 65 % of multiple trauma patients with a frequent association with orthopaedic injuries. The concept of early surgical stabilization of long-bone fractures in patients with multiple injuries became firmly established in the 1980s. However, optimal timing of long bone fracture fixation in trauma patients with associated severe traumatic brain injury has been a lively topic. The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. In recent years, some studies reported a worse outcome, with secondary brain damage, resulting from hypotension, hypoxia and increased intraoperative fluid administration. This review summarises the current evidence available regarding the management of these patients in particular the recent concept of early temporary surgical stabilization in the era of "damage control orthopaedic surgery".

On the Development and Comparative Evaluation of an Ultrasound B-Mode Probe Calibration Method

OBJECTIVE

Precise transducer calibration is an essential prerequisite for reliable surface registration based on ultrasound B-mode imaging devices. The clinical usage of a novel B-mode transducer calibration technique was evaluated and its attainable calibration precision assessed.

MATERIALS AND METHODS

The Three Wire Method and the Cambridge Calibration Method were used as reference techniques to compare the efficiency, calibration precision and spatial requirements of the different techniques. A total of 20 calibration trials were performed using each technique and were statistically evaluated for accuracy and speed.

RESULTS

The mean error characterizing the calibration precision of the Three Wire Method was 3.2 mm, obtained in a phantom with a volume of 14 x 10(6) mm(3) in 18.48 min. The Cambridge method resulted in a mean calibration error of 2.2 mm, but required a larger phantom with a volume of 35 x 10(6) mm3 to be used for a duration of 9.30 min. The proposed method yielded an average calibration error of 1.9 mm and was performed, on average, in 2 min using a phantom with a size smaller than 1 x 10(6) mm3.

CONCLUSIONS

The suggested calibration method offers decreased time and space while retaining an equivalent calibration precision when compared to established reference methods.

Femoral neck fractures secondary to renal osteodystrophy. Literature review and treatment algorithm

Pathological fractures after minor trauma in osteopenic patients are not uncommon, but fractures due to hypocalcemic convulsions in patients with renal insufficiency are relatively rare. Though similar cases have been reported in the literature, this type of fracture is still an unusual condition. The complex underlying pathophysiological mechanisms and the poor bone mineral density signify the employment of specific hardware and a different treatment approach, especially in young adults, where the salvage of the femoral head is of utmost importance. The aim of this review is to examine the specific features of the femoral neck fractures in young individuals who suffer from renal osteodystrophy and the treatment algorithm should be followed. The patient's age, the uremic condition, the skeletal maturity and the bone properties in renal osteodystrophy are examined in relation to the priorities in osteosynthesis methods. A conclusive treatment algorithm is proposed where all the relevant parameters are incorporated.

Calcaneal fracture--standardized protocol of treatment

Calcaneal fracture (CF) treatment results are not always satisfied. Our aim was to compare medium-term results between standardized and unstandardized protocol in treatment of displaced intra-articular CF. We evaluate experience of our Department where 50 patients with CF in last 5 years--Group X have been treated with standardized protocol, and compare their postoperative results with unstandardized treatment's effects in 50 patients with CF cured 5 years before--Group Y As based on Sanders classification, radiographic evaluation and Maryland Foot Score, postoperative results were satisfying in 100% X and 90% Y patients with intra-articular type I, in 86% X and 70% Y patients with type II, and sufficient in 75% X and 52% Y patients with type III, in 50% X and 33% Y patients with type IV. We suggest standardized protocol with operative treatment for types II, III and even for type IV of intra-articular CF.

Antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery

BACKGROUND CONTEXT

The objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline on Antibiotic Prophylaxis in Spine Surgery is to provide evidence-based recommendations on key clinical questions concerning the use of prophylactic antibiotics in spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of December 2006. The goal of the guideline recommendations is to assist in delivering optimum, efficacious treatment to prevent surgical site infection.

PURPOSE

To provide an evidence-based, educational tool to assist spine surgeons in preventing surgical site infections.

STUDY DESIGN

Evidence-based Clinical Guideline.

METHODS

This report is from the Antibiotic Prophylaxis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group comprised multidisciplinary surgical spine care specialists, who were trained in the principles of evidence-based analysis. Each member of the group formatted a series of clinical questions to be addressed by the group. The final questions agreed upon by the group are the subjects of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via Webcast meetings among members of the work group using standardized grades of recommendation. When Level I to Level IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified in the guideline.

RESULTS

Eleven clinical questions addressed the efficacy and appropriateness of antibiotic prophylaxis protocols, repeat dosing, discontinuation, wound drains, and special considerations related to the potential impact of comorbidities on antibiotic prophylaxis. The responses to these 11 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supported literature which was stratified by levels of evidence.

CONCLUSIONS

A clinical guideline addressing the use of antibiotic prophylaxis in spine surgery has been created using the techniques of evidence-based medicine and the best available evidence. This educational tool will assist spine surgeons in preventing surgical site infections. The entire guideline document, including the evidentiary tables, suggestions for future research, and references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.

Modified Evans technique improves plantar pressure distribution in lateral ankle instability

OBJECTIVES

Efficiency of the modified Evans technique based on clinical and radiological evaluations was determined by plantar pressure measurement.

PATIENTS AND METHODS

Eleven patients (2 females, 9 males; mean age 29 years; range 19 to 39 years) with chronic lateral ankle instability were surgically treated using the modified Evans technique. Plantar pressures of nine patients were measured pre- and post-operatively.

RESULTS

Plantar pressure below the first metatarsal head decreased in seven of the patients after surgery. Furthermore, in all of the patients, the time of initial contact decreased significantly and the pathology returned to normal limits in the postoperative period.

CONCLUSION

Modified Evans technique, despite its controversial long-term outcomes in lateral ankle instability, decreases first metatarsal head pressure and initial contact time significantly.

Myths and legends in orthopaedic practice: are we all guilty?

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.

Auditing orthopaedic audit

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.

The quality of reporting of orthopaedic randomized trials with use of a checklist for nonpharmacological therapies

BACKGROUND

The Consolidated Standards of Reporting Trials statement for the reporting of randomized controlled trials has been limited by its applicability to surgical trials. In response, a Checklist to Evaluate a Report of a Nonpharmacological Trial was recently developed by the Consolidated Standards of Reporting Trials group to address reporting issues in surgical trials. We aimed (1) to apply the checklist for nonpharmacological therapies to orthopaedic randomized controlled trials across multiple journals from 2004 through 2005, and (2) to survey authors when methodological safeguards itemized in the checklist were not reported to determine whether they actually had been performed. We hypothesized that lack of reporting of a methodological safeguard did not necessarily mean it had not been conducted.

METHODS

We searched for relevant orthopaedic randomized controlled trials across eight journals in the period from January 2004 through December 2005. We applied the Checklist to Evaluate a Report of a Nonpharmacological Trial to all eligible studies. We contacted authors to determine what methodological safeguards were actually used, especially when details remained unclear from the publication.

RESULTS

We included eighty-seven randomized controlled trials from eighty-five scientific reports. In assessing the randomized controlled trials with the checklist for nonpharmacological therapies, seventy-three studies (84%) had unclear reporting of treatment allocation concealment. Only seventeen studies (20%) mentioned surgeon skill or experience. The blinding of patients, ward staff, rehabilitation staff, clinical outcome assessors, and nonclinical outcome assessors was unclear in forty-eight (55%), sixty-three (72%), sixty-four (74%), forty (46%), and thirty-three studies (38%), respectively. Authors from forty-three randomized controlled trials responded to our survey. The results of the survey showed that 41% (95% confidence interval, 25% to 58%) of the trials had adequate allocation concealment when this had been unclear from the report. Although the surgical experience of the investigators was rarely reported, most authors (70%) acknowledged that they had defined "surgical expertise criteria" such as minimum case criteria, specialized training, and clinical performance. The survey also showed that 28% to 40% of the trials had blinding of relevant groups despite the fact that the reporting of such blinding had been unclear in the publications.

CONCLUSIONS

The quality of reporting in the orthopaedic literature was highly variable. Readers should not assume that bias-reducing safeguards that were not reported in a randomized controlled trial did not occur. Our study reinforces the need for the consistent use of a tool like the Checklist to Evaluate a Report of a Nonpharmacological Trial to assess the methodology of surgical trials.

The mechanical properties of the ligamentum teres: a pilot study to assess its potential for improving stability in children's hip surgery

The anatomic and histological characteristics of the ligamentum teres and its vascular contributions to the femoral head have been well described. The function of the ligamentum teres remains poorly understood. Although excision is the current standard in treating complete developmental hip dysplasia, we developed an interest in maintaining, shortening, and reattaching the ligament to assure early postoperative stability in developmental hip dysplasia. To analyze its potential for providing hip joint stability, we investigated the biomechanical properties of the ligamentum teres in an in vitro porcine model. Six immature porcine hips were dissected, with the proximal femur and acetabular anatomy kept intact, isolating the ligamentum teres. Specimens were loaded in tension using custom fixation rigs at 0.5 mm/s in line with the fibers. Data for displacement and force were collected and sampled at 10 Hz for duration of each test. The ligamentum teres failed in a stepwise fashion. The mean ultimate load to failure was 882 +/- 168 N. Mean stiffness and failure stress were calculated as 86 +/- 25 N/mm and 10 +/- 2 MPa, respectively. The biomechanical function of the ligamentum teres is not inconsequential. We found the ultimate load of the ligamentum teres in the porcine model to be similar to those reported for the human anterior cruciate ligament. The strength of the ligamentum teres may confirm its potential for providing early stability in childhood hip reconstructions. In the setting of dysplasia, the preservation and the transfer of the ligamentum teres to augment stability should be considered as an adjunct to open reduction.

[Clinical management of polytraumatized patients in the emegergency room--duty and assignment of the trauma surgeon]

After stabilization an optimal therapeutic strategy influences outcome in polytraumatized patients. A trauma team leader in early clinical course is necessary to optimize diagnostics and planning of further treatment. Special training systems like ATLS can help to standardize management of trauma patients. In most German trauma centers an orthopaedic trauma surgeon is the team leader in the emergency room during early clinical course of patients with multiple injuries. After identification of most threatening injuries he must decide next diagnostics steps and planning of further treatment within a short period of time. Especially in patients with abdominal bleeding and severe brain injury time is the most critical factor. If he is not able to treat these injuries alone, physicians from other specialties must be involved. The trauma team leader must be aware of different treatment concepts like early total care and damage control orthopaedics.

To err is human: quality and safety issues in spine care

STUDY DESIGN

A review of issues linking advocacy, patient safety, and quality.

OBJECTIVE

To heighten awareness of patient safety issues that require ongoing advocacy efforts by physicians treating spinal disorders.

SUMMARY OF BACKGROUND DATA

The 1999 Institute of Medicine report "To Err is Human. Building a Safer Health System" was a landmark publication that vaulted patient safety into the limelight of public awareness and media attention. The American Academy of Orthopedic Surgeons had addressed the wrong site surgery issue with its Sign Your Site Program even before the Institute of Medicine report. Several professional medical societies involved in spine care have made advocating for patient safety a priority.

METHODS

A summary of areas of advocacy efforts involving patient safety and quality. These include the Sign Your Site Program from the American Academy of Orthopedic Surgeons, Sign, Mark and X-ray from the North American Spine Society, Joint Commission on the Accreditation of Healthcare Organizations Universal Protocol, and technology assessment. Advocacy on the Federal, state, and local levels concerning patient safety is reviewed.

RESULTS

Awareness of patient safety issues has increased. Several patient safety protocols (Sign Your Site, Sign, Mark and X-ray, and the Universal Protocol) are in place. There is increased monitoring of medical errors on the state and local, especially hospital, levels.

CONCLUSIONS

Patient safety is an absolute provision of health care. Physicians need to set a personal example for compliance with existing patient safety systems such as the Universal Protocol and be active advocates for patient safety.