Care Of Orthopaedic Patients Research Articles

ACGME and ABOS Changes for the Orthopaedic Surgery PGY-1 (Intern) Year

The Accreditation Council for Graduate Medical Education (ACGME) and American Board of Orthopaedic Surgery (ABOS) recently mandated major changes to curricular requirements for the PGY-1 (intern) year for categorical orthopaedic surgery residents. Since July 1, 2013, PGY-1 residents are required to have 6 months of orthopaedic surgery rotations, 6 months of nonorthopaedic surgery rotations, and complete a mandatory surgical skills curriculum [1, 2]. The ACGME and ABOS executed these changes in an effort to improve the quality and breadth of education for interns, preparing them for more advanced orthopaedic education. These changes were prompted by shifts in general surgery procedures (from open to laparoscopic), which have reduced the operating room experience of suturing and knot tying for interns, as well as by duty hour requirements that further reduce the operating room experience for interns. Together, these shifts in first-year resident experience have resulted in less surgical training for the orthopaedic surgery intern. The new ABOS requirements, which commence on July 1, 2014, seek to offset those losses [1, 2]. This column describes the changes mandated by the ABOS and ACGME for the orthopaedic intern year, discusses some limitations associated with these changes, and offers program strategies for effective implementation.

Lessons Regarding the Safety of Orthopedic Patient Care: An Analysis of Four Hundred and Sixty-Four Closed Malpractice Claims: Matsen FA, Stephens L, Jette JL, et al. J Bone Joint Surg Am 2013;95:e201–8.

Lessons Regarding the Safety of Orthopedic Patient Care: An Analysis of Four Hundred and Sixty-Four Closed Malpractice Claims: Matsen FA, Stephens L, Jette JL, et al. J Bone Joint Surg Am 2013;95:e201–8.

Can Intravenous Paracetamol Reduce Opioid Use in Preoperative Hip Fracture Patients?

Pain due to intra- and extracapsular hip fractures is usually treated with opioid medication. Paracetamol (acetaminophen in North America) has better bioavailability when given intravenously than orally and has been successfully used in the postoperative care of orthopedic patients. However, no study has evaluated its use in the preoperative trauma patient. Our unit conducted a prospective, consecutive cohort study to investigate the opioid-sparing effect of regularly administered intravenous paracetamol compared with oral paracetamol in preoperative hip fracture patients. The total opioid dose given, based on conversion to intravenous morphine, and the reported pain score were evaluated in 75 patients. There were 28 patients in the control group who were give routine oral paracetamol and oral opioids, with morphine for breakthrough pain. There were 47 patients in the study group who received only routine intravenous paracetamol, with opioids reserved for breakthrough pain. The patients in the 2 groups had similar characteristics. The mean preoperative oral paracetamol dose for the control group was 7.2 g compared with 6.3 g in the study group. There was a significant reduction (P<.005) in the mean total intravenous morphine with intravenous paracetamol (6.5 mg) compared with oral paracetamol (21.8 mg). There was no difference in the mean pain score between the groups, 2.1 vs 1.8 (P=.3). Intravenous paracetamol had a significant opioid-sparing effect and satisfactory pain relief in preoperative hip fracture patients.

Effect of Work-hour Restrictions and Resident Turnover in Orthopedic Trauma

The resident 80-hour workweek and the July phenomenon have raised concern regarding the continuity of care of orthopedic patients in teaching institutions and its effect on postoperative complications and mortality. This study examined the effect of resident work-hour restrictions and the July phenomenon on patient outcomes after hip fracture at a large academic institution. Seven hundred twenty-two patients (mean age, 76.7 years) sustaining 319 femoral neck fractures and 403 intertrochanteric fractures between 2000 and 2010 were identified. Analysis was performed before and after July 1, 2003, as well as for the month of treatment. No difference existed in the postoperative outcome measures of delay of surgery (P=.061), complications (P=.904), and mortality (P=.981) between patients treated before and after July 1, 2003. Patients treated after July 1, 2003, had a significantly higher median number of preoperative comorbidities (4 vs 3, respectively; P<.0005). Turnover months, July and August, showed no difference in the outcome measures of delay of surgery (P=.171), complications (P=.776), and mortality (P=.524) compared with other months. This study suggests that 80-hour workweek restrictions or resident turnover months have no effect on patient care with respect to in-hospital time to surgery, complications, and mortality. This success can be attributed to ancillary staff support, physician extenders, and well-designed patient care protocols.

Application of predictive nursing procedure in care of orthopedic trauma patients

Objective To explore the clinical value of predictive nursing procedure for patients with orthopedic trauma. Methods 130 patients with orthopedic trauma were randomly divided into the observation group(72 cases)and the control group(58 patients).The control group was given conventional orthopedic care.The observation group was given predictive nursing procedure.The effective rescue time,hospital stay,hospital costs,complications,success rate of rescue and satisfaction degree with nursing for the two groups were taken for statistics. Results The effective rescue time and hospitalization time of the observation group were significantly shorter than the control group.The hospital costs reduced significantly.The complications in the observation group were significantly less than the control group,while the success rate of rescue was significantly higher.The satisfaction degree of the observation group was significantly higher than the control group. Conclusions The predictive nursing for patients with orthopedic trauma can improve treatment effect and reduce complications and hospital costs,which is worthy of promotion. Key words: Predictive nursing; Orthopedics; Trauma

The Impact of Complementary and Alternative Treatment Modalities on the Care of Orthopaedic Patients

The use of complementary and alternative medicine is widespread and popular with the lay public. Although prevalence of use varies among specific patient populations, complementary and alternative medicine, in particular herbal remedies, are widely marketed and used by orthopaedic patients. Herbal supplements can have a negative impact on the perioperative period and may interact with conventional medicines used to manage chronic conditions. Physician-patient communication often does not include the subject of alternative medicines, leading to underreporting of use. Orthopaedic surgeons should adopt methods to routinely elicit from their patients the use of complementary and alternative medicine and should monitor and counsel patients on potential side effects and drug-herb interactions. Preoperative instructions should include cessation of the use of herbal supplements.

Connecting Surgeons to Focused Orthopaedic Information

Over the past year, readers have noted several changes with The Journal, including twice-a-month issues, increased use of electronic publication options, and briefer articles, while we preserve The Journal's tradition of presenting high-quality orthopaedic information. I want to describe some other innovative changes that we have put in place to enhance the value of The Journal to your practice. A new and very valuable change has taken place with The Journal's web site as of June 1. Beyond the new look, the functionality of the web site has been upgraded markedly. The searching capability on this new site is based on “semantic technology,” a term that may not be familiar to many orthopaedists. While current searches for orthopaedic articles depend on the correct keyword entry, semantic technology assigns the correct concepts to articles. Semantic searches, which are driven more by “meaning” rather than by a specific keyword, allow subtleties of language to be more easily addressed by the computer software, producing more precise searches and linking for the user than are currently available with conventional text searches. The end result is a quicker, more focused, and more complete retrieval of orthopaedic information on the topic that you select. The new web site will provide improved capabilities to optimize the use and linkage of your computer and mobile device together. You will now be able to use your iPhone, BlackBerry, and Android to access the same items that you have been working with on your computer, providing access to orthopaedic information when you need it. The new web site improves image quality and ease of image manipulation and allows easier access to CME exams within the article that you are reading. Over the past years, the publication of supplements on surgical techniques has been highly valued and highly rated by our readers. Building on this prior success, JBJS Essential Surgical Techniques has now become a separate online publication. By presenting the surgical technique in a manner that permits portions or all of the technique to be accessed at any time that is convenient for the reader, we can integrate video and images in ways that make the publication easier to use. These techniques will continue to be linked to a peer-reviewed article describing results for a clinical series of patients for whom this surgical technique was used. The online format allows for a rolling posting of new surgical techniques throughout the year, not just at specified dates. Another innovative online publication that now is in place is the JBJS Case Connector. This publication includes more than 2000 case reports previously published in The Journal as well as the ongoing addition of new case reports after peer review is complete. The semantic technology mentioned earlier allows the computer to identify connections between the case reports that may easily go undiscovered with conventional text searches. This connectivity can be important for identifying a group of reports of uncommon conditions and will create an “early warning system” to report and aggregate individual case reports of complications or problems with new techniques or devices that otherwise may not be discovered as early. We have introduced the name “Corridor” to describe a grouping of JBJS articles, surgical techniques, and case reports by subspecialty interest. A number of these Corridors will also include an electronic newsletter that includes commentary by a respected editorial panel of orthopaedists in that subspecialty related to notable articles published outside of JBJS. A subscription to the subspecialty Corridors will be available at a nominal fee for individuals. JBJS continues to be committed to providing high-quality and up-to-date information to our readers to improve orthopaedic patient care. These new web site features and additional online publications will prove valuable to our readers and will allow the use of modern technology to meet this commitment, establishing JBJS as an integral part of your orthopaedic practice.

Commentary on an article by Kevin Willits, MA, MD, FRCSC, et al.: “Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures: A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation”

JBJS was founded by the American Orthopaedic Association in 1903 and is the Official Journal of the American Orthopaedic Association. EXCELLENCE THROUGH PEER REVIEW The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, JBJS publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal. JBJS.org is the version of record of The Journal of Bone & Joint Surgery. JBJS is published twice a month on the first and third Wednesday of each month, each time adding to a comprehensive PDF archive dating back to 1889. Additional features online include: article commenting, social sharing links, instructional videos, podcasts, and continuing medical education activities. Contributions from anywhere in the world are welcome and considered on their merits. The manuscript must be written in English and should be submitted as outlined in the Instructions for Authors. Manuscripts are subject to blinded peer review by experts and a final decision by the editor. Papers are judged by the quality and relevance of the work. Our aim is to publish the best material available from anywhere in the world.

Anesthesia Literature Review

Anesthesia Literature Review

Pressure Ulcers in Orthopaedics

Pressure ulcers can be a devastating complication in the care of orthopaedic patients. Their presence leads to increased morbidity, mortality, and cost of care. Therapy and rehabilitation cannot progress on a normal postoperative course in the patient with a pressure ulcer. Risk factors for the development of pressure ulcers include spinal cord injury, advanced age, and cognitive impairment. Several grading scales have been developed for the assessment of pressure ulcer. Frequent patient turning, close monitoring, and frequent skin checks are important factors in the prevention of pressure ulcer.

Perioperative Medication Management (POMM) Pilot: Integrating a Community-Based Medication History (MedsCheck) into Medication Reconciliation for Elective Orthopedic Surgery Inpatients

Background: Medication safety along the continuum of care is dependent on the quality of medication information at each point of transfer. The purpose of our study was to assess the impact of integrating a community-based medication history (MedsCheck) into perioperative medication reconciliation for elective orthopedic surgery patients by assessing postoperative unintentional medication discrepancies. Secondary objectives were to evaluate community pharmacist participation and patient satisfaction. Methods: Patients scheduled for elective hip or knee surgery between April and September 2008 were identified as the study population. Patients and community pharmacies were contacted to coordinate the MedsCheck prior to the pre-admission clinic visit. At the visit, the Meds Check document was used to prepare a best possible medication history, which was documented in the patient chart. Medications were reconciled postoperatively. Participants were surveyed for feedback on the process. Results: Eighty-two patients were included in the study. A MedsCheck was completed for 73.8% (31/42) of eligible patients who were contacted prior to their pre-admission clinic visit. The average number of medications per patient was 8.4. The percentage of patients with at least 1 unintentional medication discrepancy decreased from 68.4% (13/19) to 47.6% (39/82) post-intervention. Total unintentional medication discrepancies decreased from 25.6% to 10.6%. Discussion: Integrating MedsCheck into the perioperative medication reconciliation process resulted in positive outcomes. The main challenge was coordination of the MedsCheck service prior to the patient's pre-admission clinic visit. Conclusion: Integrating MedsCheck into routine perioperative care for orthopedic patients is a feasible way to facilitate pharmacist medication reconciliation and increase patient satisfaction.

Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes?

JBJS was founded by the American Orthopaedic Association in 1903 and is the Official Journal of the American Orthopaedic Association. EXCELLENCE THROUGH PEER REVIEW The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, JBJS publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal. JBJS.org is the version of record of The Journal of Bone & Joint Surgery. JBJS is published twice a month on the first and third Wednesday of each month, each time adding to a comprehensive PDF archive dating back to 1889. Additional features online include: article commenting, social sharing links, instructional videos, podcasts, and continuing medical education activities. Contributions from anywhere in the world are welcome and considered on their merits. The manuscript must be written in English and should be submitted as outlined in the Instructions for Authors. Manuscripts are subject to blinded peer review by experts and a final decision by the editor. Papers are judged by the quality and relevance of the work. Our aim is to publish the best material available from anywhere in the world.

Development and evaluation of a Continuity of Care Checklist for improving orthopaedic patient discharge from hospital

Summary In this study, we developed and evaluated a Continuity of Care Checklist (CCC) to assist nurses in comprehensively reviewing practices related to continuity of care for orthopaedic patients discharged from hospital to community. The CCC was designed to ensure nurses would attend to multiple dimensions of continuity including informational continuity, relational continuity and management continuity. To evaluate the CCC, patients discharged from an orthopaedic unit ( n =77) were interviewed about continuity of care. The CCC was then implemented and a second group of patients ( n =77) was interviewed to examine changes in care. Structured interviews were also conducted with nurses ( n =12) to learn about their experiences with the CCC. Interviews with patients revealed significant improvements in patient perceptions of information provision, involvement of informal caregivers in discharge, communication between hospital and community providers, consistency of information, and satisfaction with patient–provider relationships. Nurses who used the CCC found the tool improved standards for care and patient involvement in care. The CCC appears to be a practical tool for assisting nurses in systematically improving continuity of care among orthopaedic patients. Future directions for research and practice using the CCC are described.

Minimally Invasive Total Knee Arthroplasty Meets Computer Navigation

JBJS was founded by the American Orthopaedic Association in 1903 and is the Official Journal of the American Orthopaedic Association. EXCELLENCE THROUGH PEER REVIEW The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, JBJS publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal. JBJS.org is the version of record of The Journal of Bone & Joint Surgery. JBJS is published twice a month on the first and third Wednesday of each month, each time adding to a comprehensive PDF archive dating back to 1889. Additional features online include: article commenting, social sharing links, instructional videos, podcasts, and continuing medical education activities. Contributions from anywhere in the world are welcome and considered on their merits. The manuscript must be written in English and should be submitted as outlined in the Instructions for Authors. Manuscripts are subject to blinded peer review by experts and a final decision by the editor. Papers are judged by the quality and relevance of the work. Our aim is to publish the best material available from anywhere in the world.

Surgical Technique for Revision Total Hip Replacement

JBJS was founded by the American Orthopaedic Association in 1903 and is the Official Journal of the American Orthopaedic Association. EXCELLENCE THROUGH PEER REVIEW The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, JBJS publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal. JBJS.org is the version of record of The Journal of Bone & Joint Surgery. JBJS is published twice a month on the first and third Wednesday of each month, each time adding to a comprehensive PDF archive dating back to 1889. Additional features online include: article commenting, social sharing links, instructional videos, podcasts, and continuing medical education activities. Contributions from anywhere in the world are welcome and considered on their merits. The manuscript must be written in English and should be submitted as outlined in the Instructions for Authors. Manuscripts are subject to blinded peer review by experts and a final decision by the editor. Papers are judged by the quality and relevance of the work. Our aim is to publish the best material available from anywhere in the world.

Efficiency and Economics in Joint Arthroplasty

JBJS was founded by the American Orthopaedic Association in 1903 and is the Official Journal of the American Orthopaedic Association. EXCELLENCE THROUGH PEER REVIEW The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, JBJS publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal. JBJS.org is the version of record of The Journal of Bone & Joint Surgery. JBJS is published twice a month on the first and third Wednesday of each month, each time adding to a comprehensive PDF archive dating back to 1889. Additional features online include: article commenting, social sharing links, instructional videos, podcasts, and continuing medical education activities. Contributions from anywhere in the world are welcome and considered on their merits. The manuscript must be written in English and should be submitted as outlined in the Instructions for Authors. Manuscripts are subject to blinded peer review by experts and a final decision by the editor. Papers are judged by the quality and relevance of the work. Our aim is to publish the best material available from anywhere in the world.

Revision Total Knee Arthroplasty

JBJS was founded by the American Orthopaedic Association in 1903 and is the Official Journal of the American Orthopaedic Association. EXCELLENCE THROUGH PEER REVIEW The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, JBJS publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal. JBJS.org is the version of record of The Journal of Bone & Joint Surgery. JBJS is published twice a month on the first and third Wednesday of each month, each time adding to a comprehensive PDF archive dating back to 1889. Additional features online include: article commenting, social sharing links, instructional videos, podcasts, and continuing medical education activities. Contributions from anywhere in the world are welcome and considered on their merits. The manuscript must be written in English and should be submitted as outlined in the Instructions for Authors. Manuscripts are subject to blinded peer review by experts and a final decision by the editor. Papers are judged by the quality and relevance of the work. Our aim is to publish the best material available from anywhere in the world.

Venous Thromboembolism Debate in Joint Arthroplasty

JBJS was founded by the American Orthopaedic Association in 1903 and is the Official Journal of the American Orthopaedic Association. EXCELLENCE THROUGH PEER REVIEW The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, JBJS publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal. JBJS.org is the version of record of The Journal of Bone & Joint Surgery. JBJS is published twice a month on the first and third Wednesday of each month, each time adding to a comprehensive PDF archive dating back to 1889. Additional features online include: article commenting, social sharing links, instructional videos, podcasts, and continuing medical education activities. Contributions from anywhere in the world are welcome and considered on their merits. The manuscript must be written in English and should be submitted as outlined in the Instructions for Authors. Manuscripts are subject to blinded peer review by experts and a final decision by the editor. Papers are judged by the quality and relevance of the work. Our aim is to publish the best material available from anywhere in the world.

Surgical Technique for Revision Total Hip Replacement

JBJS was founded by the American Orthopaedic Association in 1903 and is the Official Journal of the American Orthopaedic Association. EXCELLENCE THROUGH PEER REVIEW The Journal of Bone & Joint Surgery (JBJS) has been the most valued source of information for orthopaedic surgeons and researchers for over 125 years and is the gold standard in peer-reviewed scientific information in the field. A core journal and essential reading for general as well as specialist orthopaedic surgeons worldwide, JBJS publishes evidence-based research to enhance the quality of care for orthopaedic patients. Standards of excellence and high quality are maintained in everything we do, from the science of the content published to the customer service we provide. JBJS is an independent, non-profit journal. JBJS.org is the version of record of The Journal of Bone & Joint Surgery. JBJS is published twice a month on the first and third Wednesday of each month, each time adding to a comprehensive PDF archive dating back to 1889. Additional features online include: article commenting, social sharing links, instructional videos, podcasts, and continuing medical education activities. Contributions from anywhere in the world are welcome and considered on their merits. The manuscript must be written in English and should be submitted as outlined in the Instructions for Authors. Manuscripts are subject to blinded peer review by experts and a final decision by the editor. Papers are judged by the quality and relevance of the work. Our aim is to publish the best material available from anywhere in the world.

Finding the Right Fit

At most small community hospitals, orthopaedic patients are cared for on general medical-surgical units rather than on dedicated orthopaedic units. The mixed patient population of a typical medical-surgical unit limits the amount of exposure a new graduate nurse has to care for orthopaedic patients during the unit-based orientation. In 2006, a 20-bed medical-surgical unit at a community hospital in the northeast was expecting to orient eight new graduate nurses over the course of the year. The project team recognized a need to enhance the orthopaedic portion of the unit-based orientation to prepare the graduate nurses to provide "knowledgeable and safe care" (P. ) to orthopaedic patients. This article describes the development, implementation, and evaluation of a standardized, evidence-based orthopaedic curriculum piloted in 2006. The project increased the orthopaedic competency of the preceptors, provided the new graduate nurses with a standardized introduction to orthopaedic patient care, and had an unintended benefit of improving overall staff orthopaedic knowledge that improved the consistency and quality of care for orthopaedic patients at this community hospital.