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PubMed1983

A preliminary analysis of accreditation criteria for surgical procedures by orthopedic residents.

The study reported here represented a preliminary evaluation of the accreditation criteria for orthopedic operative procedures. Because selection of the criteria has not been guided by empirical data, the extent to which they accurately reflect resident clinical experience is of concern. To examine this question, residents in an orthopedic residency program were tracked for one year, and their activities were compared with the procedure requirements established by the Residency Review Committee (RRC) for Orthopaedic Surgery. The results indicated that the RRC categories unduly emphasized activities for which there was little patient demand and failed to distinguish or require some frequently performed procedures. In their present form, therefore, the designated categories were not found to cover adequately the content of current clinical practice and thus may not appropriately reflect educational needs.

Accreditation↗
PubMed1975

Vascular radiological procedures in orthopedic surgery.

Angiographic procedures are valuable in the analysis of trauma, postoperative situation, congenital lesions, tumors, and vascular conditions producing bone and soft tissue alterations. Angiography following trauma is most helpful in determining the status of the integrity of vessels when the clinical findings are not clear, when a vascular lesion without obstruction is suspected, to establish the status of distal vessels following repair of a proximal injury and to evaluate multiple injuries in the same limb. Vascular damage is possible even when the overlying soft tissue has not been lacerated. Embolization techniques to control hemorrhage have been recently developed. Immediate or delayed effects of intraoperative damage to the vessels can be verified by angiography. Most commonly traumatic arteriovenous communications and pseudoaneurysms are discovered by angiographic means. Congenital vascular lesions may be classified as localized arteriovenous malformations, small vessel arteriovenous malformations, diffuse arteriovenous malformations, or venous malformations. Angiography localizes and defines the extent of such lesions. Skeletal or muscular congenital anomalies secondarily involving the vessels can best be defined by angiographic means. Angiography of tumors is most helpful in defining the location and extent of tumors and the site for most productive biopsy. With rare exceptions, the angiogram is not helpful in defining the histologic nature of the lesion. The angiographic studies are most helpful in lesions involving the pelvis and retroperitoneal spaces. Vascular diseases producing bone and soft tissue alterations can best be defined as to extent by angiographic means. In particular, the diabetic patient with limb ischemia should be afforded the benefit of an arteriogram to establish the presence or absence of any surgically remedial lesions in the proximal vascular supply to the limb.

Acetabulum↗
PubMed2002

Fat embolism and acute hypotension during vertebroplasty: an experimental study in sheep.

STUDY DESIGN: An experimental study of cardiovascular complications that arise during vertebroplasty was conducted. OBJECTIVE: To investigate the sequential occurrence of fat embolism and hypotension during vertebroplasty. SUMMARY OF BACKGROUND DATA: Vertebroplasty, the augmentation of vertebrae with polymethylmethacrylate, is a technique for treating osteoporotic compression fractures and achieving prophylactic stabilization of osteoporotic vertebral bodies at risk of fracture. However, there is concern that fat embolism and acute hypotension could occur as in a variety of other orthopedic procedures. METHODS: In six sheep, 6 mL of polymethylmethacrylate was injected unilaterally into L1. Transesophageal echocardiography monitored the pulmonary artery for echodense particles. Heart rate, arterial and venous pressures, and blood gas values were recorded before and for 25 minutes after injection. The lungs were subjected to postmortem histologic evaluation and compared with lung specimens from two sheep that had not undergone vertebroplasty. RESULTS: Injection of cement elicited a very rapid decrease in heart rate (within 2 +/- 1 seconds) and a rapid increase in venous pressure (within 3 +/- 1 seconds), which was followed by a fall in arterial pressure (within 5 +/- 2 seconds) (phase 1). Thereafter, showers of echogenic material appeared (within 6 +/- 1 seconds) and lasted for 138 +/- 36 seconds. A second more severe fall in arterial pressure was observed beginning at 18 +/- 2 seconds (phase 2). The injection resulted in an increase in partial pressure of carbon dioxide and a decrease in pH. The histology showed intravascular fat globules and bone marrow cells in lung tissue. CONCLUSIONS: The results suggest that immediately after cement injection, there was a reflex fall in heart rate and arterial pressure. The second fall in arterial pressure was a consequence of fat emboli passing through the heart and getting trapped in the lungs.

Animals↗
PubMed2005

Admission preoperative glucose is predictive of morbidity and mortality in trauma patients who require immediate operative intervention.

Although there have been reports in the surgical literature regarding the negative effects of preoperative hyperglycemia on outcome, the impact of elevated preoperative serum glucose levels in trauma patients is unknown. Our objectives were to determine whether preoperative hyperglycemia was associated with a greater morbidity and mortality in trauma patients who underwent surgical intervention upon admission. Prospective data was collected on 252 consecutive nondiabetic trauma patients admitted for > or =3 days who went directly to the OR from the resuscitation area. Patients were stratified by preoperative serum glucose level (<200 vs. > or =200 mg/dL) age, gender, Injury Severity Score (ISS), and other preexisting risk factors. Outcome was measured by incidence of infection, hospital (HLOS) and ICU (ILOS) length of stay, and mortality. Multiple linear regression models were used to evaluate serum glucose in relation to other preoperative risk factors. Blunt trauma accounted for the majority (86%) of the injuries. Orthopedic procedures were the most common (36%) followed by neurosurgical (22%), abdominal (22%), and thoracic (6%). Patients with elevated serum glucose had a significantly greater incidence of infection, HLOS, ILOS, and mortality matched per age and ISS. Elevated serum glucose on admission is an accurate predictor of postoperative infection, HLOS, ILOS, and mortality. A randomized prospective trial evaluating the impact of preoperative glucose control is warranted.

Abdomen↗
PubMed2003

The efficacy of convex hemiepiphysiodesis in patients with iatrogenic posterior element deficiency resulting from diastematomyelia excision.

STUDY DESIGN: Retrospective analysis was performed. OBJECTIVE: To investigate the safety and efficacy of anterior and posterior hemiepiphysiodesis in patients with iatrogenic posterior element deficiency. SUMMARY OF BACKGROUND DATA: Anterior and posterior convex hemiepiphysiodesis is a well-accepted treatment method for severe and progressive congenital scoliosis in young children. Many patients with congenital spinal deformities have intraspinal pathologies that require neurosurgical intervention with laminectomy. The efficacy of this method has not been studied in these patient populations. METHODS: Between 1990 and 2001, among 82 patients with congenital spinal deformity, 38 were treated with convex epiphysiodesis. This study included 18 of these patients (2 males and 16 females) who underwent diastematomyelia excision and had at least 2 years of follow-up evaluation. Diastematomyelia excision was performed before the orthopedic procedure in 8 patients and at the same anesthetic setting sequentially in 10 patients. The mean age at the time of the fusion was 20 months (range, 6-60 months), and the average follow-up period was 39 months (range, 24-120 months). RESULTS: The mean Cobb angle was 54 degrees (range, 31-90 degrees) before surgery and 48 degrees (range, 30-84 degrees) at the final follow-up assessment. Any increase of more than 6 degrees was accepted as progression. Eight patients (44%) had a true epiphysiodesis effect: 58 degrees (range, 40-90 degrees ) before surgery and 39 degrees (range, 30-70 degrees) at follow-up evaluation. Eight patients (44%) had a fusion effect: 49 degrees (range, 31-68 degrees) before surgery and 50 degrees (range, 37-74 degrees) at follow-up assessment. Two patients (12%) had a postoperative progression of deformity: 63 degrees (range, 54-72 degrees) before surgery and 75 degrees (range, 65-84 degrees) at follow-up evaluation. CONCLUSIONS: Convex epiphysiodesis is an effective method for patients with midline laminectomy defect as those with intact posterior elements. Because the facet joints and transverse processes usually are unaffected, the presence of midline defect does not diminish the efficacy of the technique.

Abnormalities, Multiple↗
PubMed1989

Radiation exposure from fluoroscopy during orthopedic surgical procedures.

The use of fluoroscopy has enabled orthopedic surgeons to become technically more proficient. In addition, these surgical procedures tend to have less associated patient morbidity by decreasing operative time and minimizing the area of the operative field. The trade-off, however, may be an increased risk of radiation exposure to the surgeon on an annual or lifetime basis. The current study was designed to determine the amount of radiation received by the primary surgeon and the first assistant during selected surgical procedures involving the use of fluoroscopy. Five body sites exposed to radiation were monitored for dosage. The results of this study indicate that with appropriate usage, (1) radiation exposure from fluoroscopy is relatively low; (2) the surgeon's dominant hand receives the most exposure per case; and (3) proper maintenance and calibration of fluoroscopic machines are important factors in reducing exposure risks. Therefore, with proper precautions, the use of fluoroscopy in orthopedic procedures can remain a safe practice.

Fluoroscopy↗
PubMed1997

Accidental blood contact during orthopedic surgical procedures.

A questionnaire study was carried out of all orthopedic surgical procedures in the operating rooms of a teaching hospital over an 8-week period to describe the frequency and circumstances of accidental blood contact. Blood exposure occurred in 11% of the procedures. Contamination of intact skin was the most common incident (79%); percutaneous injury occurred in 13%. The majority of the incidents were believed to be preventable.

Attitude of Health Personnel↗
PubMed1992

Treatment of osseous metastases secondary to renal cell carcinoma.

Osseous metastases occur in 25 to 50% of the patients with metastatic renal cell carcinoma. We retrospectively reviewed our experience with 14 patients who underwent 20 palliative orthopedic procedures for treatment of bony metastases secondary to renal cell carcinoma. Of the patients 6 presented after nephrectomy (group 1) and 8 presented initially with osseous metastases (group 2). Only 1 of the group 2 patients underwent adjunctive nephrectomy. Overall, 5 of 14 patients (36%) presented with fracture and 9 of 14 (64%) presented with impending fracture. Five patients required multiple procedures. A total of 7 lesions had been previously treated with external radiation. Of the 20 orthopedic procedures 17 (85%) resulted in significant functional improvement and 18 (90%) resulted in significant relief of pain. There were 4 major complications in the series, including 2 culminating in amputation. Average survival after palliative orthopedic procedures was 22 months (range 7 to 64 months) with a 1-year survival rate of 58%. Orthopedic palliation of osseous metastases from renal cell carcinoma is effective, and our experience indicates that the majority of renal cancer patients with bone metastases will survive long enough to benefit from palliative orthopedic procedures.

Adult↗
PubMed1991

Pulmonary embolism in the elderly.

The risk of pulmonary embolism increases with age. Risk factors in the elderly include stasis caused by immobility and reduced venous tone, the increasing need for operative procedures, particularly orthopedic procedures to hip and knee, and reduced fibrinolytic activity in leg veins. The diagnosis of pulmonary embolism is difficult and is made on the basis of clinical probability, lung scan findings, investigations for deep venous thrombosis and, when indicated, by pulmonary angiography. Effective prophylactic and therapeutic approaches are now available.

Age Factors↗
PubMed1996

Surgical helmet systems.

A surgical helmet system (SHS) is either a loose-fitting hood or a hood combined with an integral gown (called a toga system). SHSs are used during orthopedic procedures to decrease the patient's risk of deep wound infection by keeping skin and other particles from the surgeon's face from falling into the open surgical site. They are also used to protect surgical staff from infectious blood splashes and potentially infectious aerosols generated by power tools during orthopedic procedures - and it is this aspect of SHS use that has attracted particular attention, given the intensified interest in healthcare worker (HCW) protection (e.g., against human immunodeficiency virus [HIV], tuberculosis [TB], and hepatitis C virus [HCV]) in hospitals today. Ironically, the very factors that have led to SHSs' recent popularity may limit the need for their use, inasmuch as facilities have instituted so many other effective infection control methods against bloodborne and airborne pathogens. Although SHSs do provide splash protection against bloodborne pathogens, institutions may already by adequately protecting their staff against this hazard. In addition, they may be using SHSs to provide other types of patient and HCW protection that are already being provided by existing infection control measures. SHSs are available in a wide variety of configurations. We evaluated a total of six SHSs: one hood and one toga system each from three manufacturers. The units we tested were among each manufacturer's bestselling systems. We examined how well they would protect patients against deep wound infections and HCWs against splashes and aerosolized particles. We also evaluated their comfort and ease of use for wearers. We found that all of the SHSs provided sufficient patient protection against particles shed by the surgeon. We also found that the hood-only units and the hood components of the toga units provided sufficient HCW splash protection. (The gown portion of the toga systems failed our fluid-resistance criterion. However, we did not test the separate surgical gowns that are used with the hood-only units, and we do not know if they provide any greater level of protection than the toga fabric does). We rated all hood-only units Acceptable. We rated all toga units Acceptable-Not Recommended because the level of patient and HCW protection provided by the toga systems did not justify their significantly higher cost. We did find differences in the level of HCW respiratory protection these systems provided against aerosols. However, we do not believe that this should be a significant selection consideration because there is no established need for respiratory protection during orthopedic procedures. (Respiratory protection is needed against TB aerosols, but hip and knee arthroplasty procedures are usually elective and would be delayed on any active or suspected TB patient until the patient is noninfectious). To establish the context for this study, we first present a Guidance Section, "Do You Need Surgical Helmet Systems for Orthopedic Procedures?" In this section, we discuss the infection risks present during orthopedic procedures. We also outline the protective measures that institutions may already have in place to reduce these risks. We then discuss how SHSs fit into the infection control picture. Supplementary material in this section includes a discussion of the respiratory protection needed against Mycobacterium tuberculosis and a table of factors affecting the choice among SHSs, respirator masks, and surgical masks for patient and HCW protection. Ultimately, the choice to use SHSs may be dictated by the training and preference of the surgical staff. But this Evaluation will help facilities to (1) make this decision and, if appropriate, (2) select the best system for their needs...

Blood-Borne Pathogens↗