Clinical orthopaedics and related research
-
Clin. Orthop. Relat. Res. · Apr 2007
Success of clinical pathways for total joint arthroplasty in a community hospital.
Clinical pathways for total joint arthroplasty have been implemented successfully during the past decade. We report the results of pathway use for primary elective total hip and total knee arthroplasty in a community teaching hospital. We evaluated pathway efficacy using patient data forms and the hospital's financial database. ⋯ Despite higher expected increases in the overall healthcare cost during the time of implementation (3 years), direct cost increases were limited to 3.48%. The key elements contributing to pathway success included preoperative patient education, standardized orders derived from evidence-based medicine, and a nurse practitioner who championed the pathway and ensured compliance. We recommend clinical pathways for patients having total joint arthroplasties to reduce length of stay, facilitate effective resource use, and preserve quality of care without compromising patient satisfaction or safety.
-
Clin. Orthop. Relat. Res. · Apr 2007
Unexpected absence of effect of rhBMP-7 on distraction osteogenesis.
We asked whether locally applied rhBMP-7 with a Type I collagen carrier could enhance the consolidation phase in distraction osteogenesis. We performed unilateral transverse osteotomy of the tibia in 28 immature male rabbits. In half the animals (14 rabbits), 70 microg rhBMP-7 (28.5 mg rhBMP-7/CC, OP-1) was applied locally on the day of the osteotomy; the control group (14 rabbits) had no local application. ⋯ Ultrasonographic evaluation revealed the development of a cyst in the regenerate in 92% of the animals in the rhBMP-7/CC group versus 0% in the control group. Ultrasonography and histomorphometry showed delayed regenerate development in the rhBMP-7/CC group. We suggest the poor results related to the relatively large bulk of the solid carrier of the OP-1 that might have acted as a mechanical obstacle to osteogenesis.
-
Clin. Orthop. Relat. Res. · Apr 2007
Lateral hip pain: does imaging predict response to localized injection?
Lateral hip pain is a common complaint in patients with a history of lower back pain from spinal disease. These patients often are diagnosed and treated for trochanteric bursitis because of localized pain and tenderness in the lateral hip. We presumed numerous scintigraphic features could provide diagnostic criteria for diagnosing gluteus medius tendinitis and trochanteric bursitis. ⋯ The major predictor of relapse of pain after injection in 18 patients was the presence of moderate to severe lumbar degenerative disease seen on scintigraphic imaging. We propose a mechanistic model of the greater trochanteric pain syndrome to explain the interrelationship and response to therapy. Scintigraphy can provide sensitive and specific diagnoses of gluteus medius tendinitis and trochanteric bursitis.
-
Epidural hypotensive anesthesia can, in addition to imparting numerous intraoperative benefits, provide excellent postoperative pain control for patients having joint arthroplasties. However, because of the risk of epidural hematoma, epidural anesthesia is not coadministered with anticoagulation in some centers. We retrospectively ascertained, by chart review, the incidence of epidural hematoma in 11,235 patients having 12,991 knee arthroplasties at our institution who received oral anticoagulation and epidural anesthesia for their surgery. ⋯ For 1030 patients (1038 knees) whose charts were reviewed in detail, the mean international normalized ratio at the time of removal of the epidural catheter was 1.54 (range, 0.93-4.25). We identified no other complications related to the coadministration of epidural anesthesia and warfarin. Although administration of epidural anesthesia in patients with coagulopathy can be detrimental, we recognized no cases of epidural hematoma causing neurologic symptoms in patients receiving controlled oral anticoagulation after total knee arthroplasty.
-
Preserving femoral head vascularity during hip resurfacing may avoid femoral neck fractures and late femoral loosening. The posterior approach and notching of the femoral neck influence femoral head perfusion. However, it is not known if standard preparation of the femoral head during hip resurfacing can disrupt blood flow. ⋯ Nine hips had a mean decrease of 70% in femoral head blood flow after standard reaming and preparation. The data suggest femoral head reaming during hip resurfacing substantially impacts blood flow to the femoral head and infers the extra osseous blood supply is still important in the arthritic femoral head. To avoid damaging the retinacular vessels, surgeons should direct the cylindrical reamer superolaterally staying as close as possible to the inferomedial neck.