The American journal of orthopedics
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Encounters with racist patients can be distressing, damage the physician-patient relationship, and threaten the collegial environment of the health care setting. Although policies guiding physician interactions may exist, providers may be uncomfortable and left vulnerable in racially charged interactions. ⋯ Unsuccessful attempts at relationship salvage should be further guided by ethics teams, and in cases of a continued impasse, physicians should absolve themselves of medical duties provided that an appropriate alternative provider is available. Although racism in the health care setting can present a reasonable window to generate productive dialogue to improve race relations, a deeply entrenched and pervasive mindset can be difficult to reverse and should not impede the primary goal of providing timely patient care.
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We conducted a study to determine differences in knee pain in patients who underwent either traditional infrapatellar nailing or suprapatellar nailing. From a single institution, we identified patients who had an isolated tibial shaft fracture (Orthopaedic Trauma Association type 42 A-C) surgically fixed with an intramedullary nail between 2009 and 2012. Each patient was contacted by telephone by an investigator blinded to surgical exposure, and the Oxford Knee Score (OKS) questionnaire was administered. ⋯ Compared with the infrapatellar approach, suprapatellar nailing improved radiographic reduction in the sagittal plane (2.90° vs 4.58°; P = .044) and required less operative fluoroscopy time (81 vs 122 s; P = .003). We found no difference in OKS between the infrapatellar and suprapatellar approaches. Although further study is needed, the suprapatellar entry portal appears to be a safe alternative for tibial nailing with use of appropriate instrumentation.
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We conducted a study to determine the overall incidence and long-term clinical and functional outcomes of patients with malunion after nonoperative management of humeral shaft fractures. Fifteen patients with radiographic malunion (>20° angulation or shortening of :ge;2.5 cm) were identified, and their medical records retrospectively reviewed for information about their injuries and treatment. Long-term outcomes were assessed with a self-reported questionnaire, the DASH (Disabilities of the Arm, Shoulder, and Hand) form, and physical examination. ⋯ However, 75% also reported a noticeable cosmetic deformity; for 25% of patients, this was a major reason for dissatisfaction. Our findings suggest that malunion may be more common than previously thought but, for a majority of patients, does not cause significant pain, functional limitations, or dissatisfaction. However, patients should be counseled about the high likelihood of cosmetic deformity, which they may find bothersome.
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Attention to patient satisfaction is critical in today's health care environment-satisfaction surveys inform the development of hospital performance standards and can influence an institution's rankings and reimbursement. The effectiveness of postoperative pain management can affect clinical outcomes and also influence the patient's perception of the overall surgical experience. Ample clinical- trial data now exist that demonstrate the benefits of periarticular injections as part of a multimodal regimen in patients undergoing joint arthroplasty. ⋯ The US Food and Drug Administration has approved liposomal bupivacaine for injection into the surgical site to produce postsurgical analgesia. The safety and efficacy of liposomal bupivacaine has been demonstrated in clinical studies in multiple types of surgical procedure, including double-blind, randomized, controlled clinical trials that involved over 1300 patients. In a case-control study comparing clinical and economic parameters before and after the introduction of liposomal bupivacaine as a component of the multimodal perioperative pain regimen for total joint arthroplasty, liposomal bupivacaine provided improved overall pain scores, an increase in patients reporting a pain score of 0, increased patient satisfaction, decreased length of stay, and a decrease in overall costs.
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Case Reports
Tension Pneumothorax After Ultrasound-Guided Interscalene Block and Shoulder Arthroscopy.
Interscalene brachial plexus anesthesia is commonly used for outpatient arthroscopic shoulder procedures. Ultrasound guidance has helped to minimize the cardiac, neurologic, and pulmonary complications associated with this block. ⋯ We present a case of tension pneumothorax in a patient undergoing arthroscopic rotator cuff repair under both interscalene regional and general anesthesia. Surgeons and anesthesiologists must remain aware that ultrasound-guided interscalene blocks may be associated with pneumothorax and must initiate treatment expeditiously.