Clinical orthopaedics and related research
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Clin. Orthop. Relat. Res. · Dec 2006
Multimodal analgesia without routine parenteral narcotics for total hip arthroplasty.
Methods for managing pain after a total hip replacement have changed substantially in the past 5 years. We documented the outcome of patients treated with a multimodal pain program designed to avoid parenteral narcotics. Avoidance of parenteral narcotics can essentially eliminate the complications of respiratory depression, ileus, and narcotic-induced hypotension. ⋯ Emesis occurred in five patients (3.6%) with two incidences in the recovery room. One hundred and thirty-eight patients (98.6%) were discharged home at a mean of 2.7 seven days postoperatively with 98 (70%) on a single assistive device. The multimodal pain management program, which avoided parenteral narcotics, was effective in providing pain relief, nearly eliminating emesis, and eliminating the severe complications of respiratory depression, urinary tract infection and ileus, as well as accelerating function.
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Clin. Orthop. Relat. Res. · Nov 2006
ReviewRationale for low-molecular-weight heparin prophylaxis after total knee arthroplasty.
Low-molecular-weight heparin has been studied extensively in total knee arthroplasty (TKA) and provides highly effective and safe prophylaxis against deep venous thrombosis (DVT). Low-molecular-weight heparin received the highest rating (A1) in the American College of Chest Physicians recommendations for DVT prophylaxis after elective TKA. Prevalence of DVT with low-molecular-weight heparin prophylaxis was 33% in TKA data pooled from six randomized studies, with a proximal DVT rate of 7.1%. ⋯ Low-molecular-weight heparin, given by subcutaneous injection, can be started before surgery or after surgery. A synthetic pentasaccharide (fondaparinux), which received an A1 rating in the American College of Chest Physicians recommendations, also is available. As with all treatments, the benefit must be considered against the risk when using these anticoagulants.
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Clin. Orthop. Relat. Res. · Oct 2006
Case ReportsTwo potential causes of EPL rupture after distal radius volar plate fixation.
Rupture of the extensor pollicis longus tendon can occur after volar plate fixation of dorsally comminuted distal radius fractures. We attempted to identify the etiology of extensor pollicis longus tendon injury after volar plate fixation of the distal radius and potential solutions to this problem. After describing two case reports, we examine six cadaveric specimens and retrospectively review 10 selected patients to evaluate possible technique refinements to minimize damage to the extensor pollicis longus tendon during volar plating of the distal radius. ⋯ In addition, after reduction and plate fixation, bone fragments or dorsal gapping may predispose the extensor pollicis longus tendon to injury. We recommend either using shorter screw lengths or leaving the implicated plate holes unfilled. In addition, we suggest consideration of an open assessment of the third extensor compartment, if indicated, as performed through a small dorsal incision ulnar to Lister's tubercle.
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Clin. Orthop. Relat. Res. · Aug 2006
Historical ArticleABMS' Maintenance of Certification: the challenge of continuing competence.
The American Board of Medical Specialties, since its inception in 1933 as the Advisory Board for Medical Specialties, is concerned with the education, training and certification of physician specialists. Although not perfect, the initial certification process is quite good and accomplishes its intended purpose. However, initial certification is based on a primarily knowledge-based "snapshot." The newly developed Maintenance of Certification Program will evaluate the competencies, medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement and systems-based practices believed to be necessary and sufficient for certified physicians to have and maintain throughout their entire professional career. Furthermore, the process will focus on education and assessment to encourage continuous quality improvement in clinical practice.
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Clin. Orthop. Relat. Res. · Aug 2006
ReviewProfessionalism and medicine's social contract with society.
Medicine's relationship with society has been described as a social contract: an "as if" contract with obligations and expectations on the part of both society and medicine, "each of the other". The term is often used without elaboration by those writing on professionalism in medicine. ⋯ The recognition of these expectations is important as they serve as the basis of a series of obligations which are necessary for the maintenance of medicine as a profession. Mutual trust and reasonable demands are required of both parties to the contract.